4th National One Health Conference

Report of the Conference Paro, Bhutan, 19-21 December 2018 Fund supported provided by WHO Conference organized by Department of Livestock, Ministry of Agriculture and Forests and Department of Public Health, Ministry of Health

Table of Contents 1 Introduction ...... 1 2 Objectives of the One Health Conference ...... 3 3 Session 1: Opening session ...... 3 4 Session 2: Updates on One Health activities...... 5 4.1 Follow up of 3rd National One Health Workshop resolutions: Mr Rinzin Kinga Jamtsho, MoH ...... 5 4.2 Update on One Health Activities from Public health sector: Dr Sonam Wangchuk, Royal Centre for Disease Control, Ministry of Health ...... 8 4.3 Update on One Health Activities from Animal health sector: Dr Tenzin, National Centre for Animal Health, Department of Livestock ...... 9 4.4 Update on One Health Activities from Wildlife sector: Dr Kinley Choden, Nature Conservation Division, Department of Forests and Park Services ...... 10 4.5 Update on One Health Activities from Food safety sector: Dr Kinley Penjore, BAFRA ...... 11 4.6 Emerging and Re-emerging Infectious Diseases Scenario and Threat to BHUTAN: Dr Sonam Wangchuk, Royal Centre for Disease Control, Ministry of Health ...... 11 4.7 South Asia One Health Disease Surveillance Network: Dr Sithar Dorjee, Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu, Bhutan ...... 12 5 Session 3: Performance Evaluation of human and animal health services ...... 14 5.1 Joint External Evaluations for IHR Core Capacities: Mrs Jamyang Chodon, Ministry of Health ...... 14 5.2 Findings and recommendations of the OIE-PVS Evaluation: Dr Karma Rinzin, Department of Livestock .... 15 5.3 Findings and Recommendations of National IHR-PVS Bridging Workshop: Dr Sithar Dorjee, Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu, Bhutan ...... 16 6 Session 4: Projects ...... 17 6.1 One health approach to determine antimicrobial resistance profile in Salmonella isolates collected from human, animal and food samples: Dr RB Gurung, National Centre for Animal Health, Serbithang ...... 17 6.2 An overview of Fleming Fund AMR project: Dr. Karma Rinzin, Department of Livestock ...... 18 7 Session 5: AMR and Food safety ...... 20 7.1 AMR surveillance in children under 5 years of age with diarrhoeal cases: Mr Tshering Dorji, Royal Centre for Disease Control...... 20

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7.2 Foodborne Disease Outbreak Investigation: A case study of One Health Approach: Dr Sithar Dorjee, Khesar Gyalpo University of Medical Sciences of Bhutan ...... 20 7.3 Microbial load and prevalence of Salmonella in imported fresh beef at different points of meat handling: Mr Kaling Dorji, Bhutan Agriculture and Food Regulatory Authority, Thimphu ...... 21 7.4 Antibiotic resistance of Escherichia coli causing diarrhea; practices and factors influencing use of antibiotics in swine farms in central region of Thailand: Dr Narayan Pokhrel, Dzongkhag Veterinary Hospital, Pemagatshel 22 8 Session 6: Zoonotic diseases ...... 23 8.1 Emergence of Brucellosis in Bhutan: animal Brucellosis and human case report: Dr RB Gurung, National Centre for Animal Health, Serbithang ...... 23 8.2 Status of Multi-drug resistant tuberculosis in the country (2014 – 2018): Mr Karchung Tshering, Royal Center for Disease Control ...... 24 8.3 A Case-Control Study to Identify Risk Factors of Multi-Drug Resistance Tuberculosis (MDR-TB) among New Pulmonary TB Patients in Bhutan, 2018: Dr Tandin Zangpo & group, Dechencholing BHU-I, Ministry of Health, Thimphu ...... 25 8.4 Acute Undifferentiated Febrile Illness surveillance: Preliminary finding of causing agents: Dr Sonam Wangchuk, Royal Center for Disease Control ...... 25 8.5 Chronology of HPAI-H5N1 outbreak in Bhutan and genetic characterization of virus involved: Dr RB Gurung, National Centre for Animal Health, Serbithang ...... 26 9 Session 7: Diseases at human-animal-wildlife interface ...... 27 9.1 Synantrophic rodents as reservoir of zoonotic pathogens in Bhutan: Dr Yoenten Phuentshok, National Centre for Animal Health ...... 27 9.2 Bat diversity in Bhutan – implications for emerging infectious disease control: Mr Sangay Tshering and Tshering Gyelpo, College of Natural Resources, Royal University of Bhutan, Lobeysa ...... 28 9.3 Ecology of Lyle’s Flying Fox (Pteropus lylei) at the bat-human interface in Cambodia: Dr Kinley Choden, Nature Conservation Division ...... 29 10 Session 8: Community Perceptions and Practices ...... 31 10.1 Determinants of Rabies PEP seeking and compliance behaviour – Hospital and commmuniy-based contact tracing survey: Dr Kinley Penjor and group, Dewthang Military Hospital, Ministry of Health ...... 31 10.2 One Health profile of local communities living within a protected area in Bhutan: Dr Kinley Choden, NCAD 32 10.3 Knowledge, Attitude, and Practice survey rabies among cattle owners in two districts of Bhutan: Dr Sangay Rinchen and group, Regional Livestock Development Centre, Tsimasham ...... 33

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11 Session 9: Disease Prevention and control Strategies ...... 34 11.1 Strategic framework for elimination of dog mediated rabies in Bhutan: Dr Tenzin, National Centre for Animal Health, Department of Livestock, Serbithang ...... 34 11.2 Strategy for prevention and control of zoonoses: Mr Rinzin Kinga Jamtsho, DoPH, MoH ...... 36 11.3 Bhutan Wildlife Health Strategy: 2019 – 2028: Dr Kinley Choden, NCD ...... 37 11.4 Animal welfare with focus on dog population management in Bhutan: Dr Karma Rinzin, Department of Livestock...... 39 12 Session 10: Group work and plenary presentation ...... 41 13 Session 11: Closing session ...... 47 13.1 Conference Resolutions: Dr. Sangay Rinchen, Chief Rapporteur ...... 48 14 Annex ...... 50 14.1 Annex 1: Conference Agenda ...... 50 14.2 Annex 2: List of participants ...... 54

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1 Introduction

Of the growing list of human pathogens, more than 60% originates from animals. Among emerging infectious diseases, 75% are zoonotic in nature which mainly emerges at the animal-human-ecosystem interface. The emerging and re-emerging zoonoses including human immunodeficiency virus, severe acute respiratory syndrome (SARS), West Nile virus, Nipah virus, Ebola, dengue haemorrhagic fever, and most notably, highly pathogenic avian influenza (HPAI) have caused substantial morbidity and mortality to the human and animal populations, adverse effect on economies and livelihood systems of many countries in the world, and presented immense challenges for public health and animal health authorities. About 80% of the agents with potential bioterrorist use are zoonotic pathogens.

To mitigate the risk of emerging pathogens at animal-human-ecosystem interface, the One Health Approach has been developed and recognized as a holistic and important approach by the international organizations like World Health Organization (WHO), World Organisation for Animal Health (OIE) and Food and Agriculture Organizations of the United Nations (FAO). The One Health concept was formally endorsed during the 7th International Ministerial Conference on Animal and Human Pandemic Influenza held in Hanoi, Vietnam in April 2010 (IMCAPI Hanoi 2010), resulting in the Hanoi Declaration, which emphasized not only the need to continue the control of HPAI and H1N1 infection in humans, but also the importance of extending the lessons learned from HPAI to other emerging diseases. Following this meeting, the WHO‐FAO‐OIE prepared a tripartite concept note “Contributing to One World, One Health - A Strategic Framework for Reducing Risks of Infectious Diseases at the Animal-Human-Ecosystems Interface”. The importance of One Health approach is now increasingly becoming recognized in many countries because it provides a strategy that increases the effectiveness and efficiency of interventions for controlling diseases through multi-sector approach.

Bhutan is a landlocked country with an area of 38,394 square kilometers with a forest cover of 72 percent. The population is largely rural, with 79 percent living in villages, and depends on subsistence agriculture and livestock rearing for livelihood. This results in close interaction with domestic and wild animals. Moreover, Bhutan has a fragile ecosystem and it is vulnerable to the impacts of global warming and climate change, and also susceptible to natural disasters such as floods and earthquakes. As Bhutan is located in the South Asia region, which is identified as one of the global hotspots for emerging and re- emerging infectious diseases and having long porous international borders, the country faces serious public health threats from emerging and re-emerging infectious diseases, including antimicrobial

1 resistance (AMR) issues. As such, the zoonotic diseases remain a major concern to both animal and human health in Bhutan. The increasing demand and establishment of intensive farming in livestock and poultry and the increasing ease and frequency of animal or animal products movement further increases the risk of such disease emergence and a significant challenge for prevention and control. Although some amount of understanding and collaborative activities have been initiated in the past in the areas such as prevention and control of HPAI and rabies, there is an imperative need for establishing a firm institutional linkage with clear cut working relation mainly between the Ministry of Health and the Ministry of Agriculture and Forests.

Considering the severe risks of emergence of emerging and re-emerging infectious diseases, and recognizing the benefits of one health approach, the Ministry of Agriculture and Forests (MoAF) and Ministry of Health (MoH) provided importance to formally institutionalize the One health program in Bhutan. The two Ministry developed Bhutan One Health Strategy Plan (2017-2022) which was formally approved by the Government in 2017. Following that the Memorandum of Understanding was signed between MoAF, MoH and other collaborating partners (National Environment Commission (NEC), Ministry of Home and Cultural Affairs and Universities) on 3rd November 2017 on the eve of World One Health Day. The proposal for establishment of One Health Secretariat is currently being pursued with the Royal Civil Service Commission. Both the Ministry accorded priority to set up One Health Secretariat at Royal Centre for Disease Control in the proposed Fleming Fund Project on AMR. The two Ministry also organized three round of National One Health Workshop/ Conference in the past to mainly sensitize human and animal health personnel and other stakeholders at national, regional and district levels on the concept of One Health in preventing and controlling the priority zoonoses through multi-sectoral coordination and collaboration. In August 2016, Bhutan also hosted the Asia-Pacific Zoonotic Influenza Workshop organized by WHO, OIE and FAO which was attended by the human and animal health officials from 32 Member States.

The OIE fielded series of missions to carry out the evaluation of the performance of veterinary services in Bhutan. The first PVS mission was field in June 2008 followed Gap Analysis Mission in November 2009 and a follow-up mission in March 2015. The OIE also fielded Laboratory Mission in January 2016. Similarly, the WHO fielded International Health Regulations Joint External Evaluation mission in November 2017. Bhutan is also one of the few countries who successfully carried out the National IHR- PVS Bridging Workshop which was conducted in March 2018. The National Bridging Workshop came up with number of recommendations to improve the prevention and control of infectious diseases at the human-animal-environment interface.

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Although there is need to organize One Health Workshop on annual basis, MoAF and MoH is not able to host the event due to unavailability of the fund. The need to have annual One health workshop was recommended by the National IHR-PVS Bridging workshop as well. Therefore, 4th National One Health Conference was proposed and financed by WHO from 19-21 December 2018.

2 Objectives of the One Health Conference

The main objectives of the conference were to: 1. To provide an update on situation of zoonotic diseases in the country and to share the updated scientific information of recent emergence of zoonotic diseases that may have implications to human-animal-wildlife health in the country 2. To strengthen collaboration among relevant sectors (Livestock, Health, BAFRA, Wildlife and other stakeholders) in preventing and controlling of zoonoses; 3. To share experience(s) and expertise of any successful disease control interventions instituted by the stakeholders and new technologies/tools/approaches being practiced in Bhutan and elsewhere. 4. To present the research findings in the areas of one health. 5. To come up with action plan for implementation of one health activity in the 12th FYP and integrated action plan for coordinated response to zoonotic diseases. 6. To align the recommendations of the National IHR-PVS National Bridging Workshop with the 12th FYP of the respective agencies.

3 Session 1: Opening session

Dr Karma Rinzin, Chief Veterinary Officer, Department of livestock, Ministry of Agriculture and Forests extended his greetings and warm welcome and all the participants representing the Ministry of Agriculture and Forests, Ministry of Health and other relevant OH partners for the conference. He provided a brief background of the annual One Health conference which was first conducted in 2013, in Phuentsholing, Bhutan. He also emphasized that ever since the OH concept has been adopted tremendous achievements have been made in the field of One Health starting from the development of the One Health Strategic document, signing of the MoU between Ministry of Health and Ministry of Agriculture and Forests and other relevant stakeholders, and various OH research activities. He informed the gathering that the process has led to institutionalization of OH secretariat which is currently being pursued with the Royal Civil Service Commission (RCSC). He also stressed on enhancing collaboration

3 among various stakeholder in effective early detection and response, and containment of zoonotic diseases through enhanced sharing of resources and information.

Dr Pandup Tshering, Director General of the Department of Medical Services, Ministry of Health in his opening remark expressed his pleasure and honour to address the conference. Given that Asia, particularly Southeast and South Asia being the global hotspot for emerging and re-emerging, he stressed on the importance of adopting the OH in mitigating the public health and economic impacts resulting from these diseases. Giving a brief background on the twelve birdflu outbreaks that Bhutan has experienced since 2010, he acknowledged the effort of the different stakeholders in successfully containment the outbreaks without experiencing a single human case. Similarly, he also applauded the effort of the relevant stakeholders in early detection and effective response to rabies outbreaks in dogs that resulted in zero human cases in 2017 and 2018. Dr Pandup Tshering also spoke on the progresses that had been made under the umbrella of One Health particularly pertaining to instituting the OH secretariat. He acknowledged that getting different sectors working together for a common identified goal is very difficult however, the OH collaboration between different stakeholders has risen above all the odds and achieved greater heights in a very short span of time. Given these successes, he stressed the floor to carry forward this effort, which is a proven and effective tool in mitigating the impact of the diseases at the human-animal-ecosystem interface. He thanked all the stakeholders for the great work and re-committed his support for the OH initiative in the country.

Dr. Tashi Samdup, Director General of the Department of Livestock, Ministry of Agriculture and Forests in his remark informed the floor that Bhutan has come up a long way to operationalize OH concept in the country. He mentioned that Bhutan is in the forefront in terms of carrying forward OH activities in the region and this has been only possible due to the dedication and handwork of the relevant agencies. Given that more than 60% of the human pathogens are of animal origin and more than 75% of the re- emerging infectious diseases are reported in animals, he stressed on enhancing OH approach remains critical in mitigating the public health and economic impact. Dr. Tashi Samdup also mentioned some of the crucial milestones achieved since starting this program some of which are, development of OH strategic plan, signing of the MoU between various stakeholders, joint researches and surveillance program, which have led to formulate evidence-based disease prevention and control plan. He also stressed the importance of swift containment of infectious diseases that minimize or reduce the risk to public health and the livelihoods of farmers. Dr. Tashi also emphasized on information sharing as one of the crucial component. On behalf of the MoAF, he committed full support to make OH a successful and operational program to ensure a common goal of good health.

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Mr. Rinzin Jamtsho, Chief Program Officer, Department of Public Health, Ministry of Health thanked the Director Generals, Directors and all the participants for showing interests and participating the conference. He also thanked all the speakers for agreeing to present their findings and expertise in the forum. He also thanked WHO for funding this conference. He expressed acknowledgements to the organizer and the personnel working behind the scene in making this conference a successful one. He wished fruitful deliberations and hoped for a productive outcome.

Dr. Tenzin, Head, Disease Prevention and Control Unit, National Centre for Animal Health, DoL presented session wise agenda and the floor adopted the agenda. Rapporteurs for the conference were introduced. Given that the conference attendees come from different agencies, a brief introduction was given by each participant before the start of the presentation session.

4 Session 2: Updates on One Health activities

4.1 Follow up of 3rd National One Health Workshop resolutions: Mr Rinzin Kinga Jamtsho, MoH

Resolution #1: With OH, the collaboration between stakeholders have greatly strengthened, especially at the central level; for e.g. the joint works on Brucellosis, Leptospira, CCHF conducted between NCAH and RCDC. However, there is weak coordination and information sharing amongst the stakeholders at the field level. Therefore, the house recommended developing a framework for information sharing and strengthening coordination amongst the stakeholders at all levels.

Status of Implementation: No separate framework was developed for strengthening information sharing system. However, all national disease prevention and control plans including HPAI, Anthrax, Rabies, Scrub Typhus, Foot and mouth disease and PPR in animals have a section mentioning information sharing mechanism for surveillance and outbreak investigation and containment process. Moreover, NCAH has real-time disease outbreak information system (disease outbreak information shared to all the relevant stakeholders immediately through e-mails to over 300 plus stakeholders). RCDC- has web based and SMS reporting system for all notifiable diseases and syndrome. Any outbreak, zoonotic or foodborne notified by health centers in the system are shared to relevant stakeholders through emails. BAFRA has launched BAFRA quarterly e-Newsletter which covers information on the achievements and

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Highlights of BAFRA relating to Bhutan’s Biosecurity, Biosafety and Food Safety in the Kingdom on quarterly basis

Resolution #2: The response to the outbreak of HPAI by all the stakeholders was a good example of collaboration and the floor felt that it should be replicated for other zoonotic diseases as well. Hence, the floor recommended for joint outbreak investigation of zoonotic and food borne disease outbreaks.

Status of Implementation: As recommended, disease outbreak investigation and containment activities for zoonotic and foodborne are being implemented jointly through OH approach at all levels. For example, we have involved multi-sectoral stakeholders for rabies outbreaks in Trashigang, Panbang, Chukha and Samtse foodborne disease outbreak in Thimphu

Resolution #3: Owing to the importance of food borne diseases and food safety in the country, the floor felt that there should be clear delineation of the roles and responsibilities of BAFRA and RCDC with regards to food borne disease outbreaks. However, the limited capacity at various levels of stakeholders without specialized technicians and laboratory facilities at the moment are some of the contributing factors to occupational health hazards and food safety. Hence, the floor suggested for the need to strengthen and equip the relevant institutions to enable them conduct effective surveillance and investigations during the outbreaks related to food-borne diseases.

Status of Implementation: There is no confusion in the roles & mandates for preventing food borne outbreaks. BAFRA is responsible for taking lead in preventing foodborne outbreaks. However, in the event of foodborne outbreaks, a collaborative mechanism between BAFRA, RCDC and other stakeholders are in place for timely disease investigation (e.g. the food borne outbreak investigation at Lama Bakery in June 2017, was conducted through One Health approach). Furthermore, RCDC and BAFRA has also initiated to conduct joint foodborne illness surveillance in selected sites to understand the foodborne illness pathogen in clinical specimens and high risk foods.

Resolution #4: In order to meet the objective of eliminating canine mediated rabies by 2030 and in view of the absence of active rabies surveillance system currently, it was suggested that the rapid rabies test and post mortem be performed on all suspected rabid animal deaths including wild animals. The rationale behind this is to detect the absence or presence of the disease in all the parts of the country.

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Status of Implementation: Veterinary laboratories in the country have been performing postmortem examination and laboratory tests on various animals’ species carcasses as part of surveillance to confirm rabies in animals. Rabies surveillance system is also included in the National Rabies Prevention and Control plan 2017.

Resolution #5: Owing to the outbreak of Giant African Land Snails (GALS) population in Gelpozhing, Mongar the BAFRA had been actively involved in the control of GALS population. It has almost become an annual event and there is a heavy financial implication involved in the control. As such, BAFRA is facing difficulty without much assistance from other concerned agencies including general public. The GALS are known to transmit diseases to humans causing public health concerns. In addition, it has also serious implication to environment and animal health. Therefore, the floor felt that it is necessary to sensitize the general public and involve all the relevant stakeholders including National Environment Commission (NEC). The floor also suggested that a collaborative research in the control of GALS population should be initiated; for instance, destroying the larvae and eggs with the adult snails.

Status of Implementation: In September 2016, a KAP study was conducted with the objective to study the GALS status in Bhutan and evaluate the containment program at Gyelposhing and Mongar. A well- structured questionnaire was designed, pretested and administered to the public in the study area. 83% of the respondents were found to be aware of the risk posed by the GALS and means of spread of GALS. 91% of the respondents thought that the containment program must continue every year. However, 51% of the respondents thought, the containment strategy was not adequate to address the problem. Since the outbreak of GALS in 2010, there was increase in numbers of GALS intercepted at strategic point until 2015. The number of GALS declined from 2016 and no outbreak was reported in 2018. The reason for drop in GALS could be credited to the intense awareness program given to the general public and preventive measures taken by BAFRA.

Resolution #6: The wild life plays an important role in the zoonotic disease transmission and due to lack of disease information in wild life population; it has become imperative to conduct disease screening of zoonotic importance to establish baseline information. Therefore, the floor recommended to formally institutionalize the disease surveillance and screening in wild animals between the NCAH and Wildlife Conservation Division.

Status of Implementation: The Technical Core Working group was formed comprising of technical experts from wildlife and animal health and KGUMSB. The team drafted Wildlife Health Strategy Plan and incorporated all aspects of institutionalization and infectious disease surveillance at human-livestock-

7 wildlife interface. Once the plan is approved by the MoAF, it will take care of all aspects of wildlife heath surveillance, researches and collaboration among relevant partners. The draft plan will be presented on the 3rd day of this conference.

Resolution #7: For sustainable prevention and control of zoonoses in the country, it is important to institutionalize OH approach. It was deliberated at length whether there is need for a permanent OH Secretariat in order to have more focus on the program. The floor suggested that the OH Tasks Force should discuss on the pros and cons of the permanent and rotational OH secretariat and submit to the cabinet accordingly.

Status of Implementation: As recommended, the need to establish permanent OHS at RCDC was justified in the Strategic Plan document. This was endorsed by the 119th Lhengye Zhungtshog held on 22 November 2016. Currently, the establishment of One Health Secretariat is being pursued with the Royal Civil Service Commission

Resolution #8: The presentation on the Bhutan One Health Strategic Plan (BOHSP) raised concerns over the disparity in budgeting for different activities and hence suggested for the OH core group to revisit the costing before submitting to the cabinet.

Status of Implementation: As recommended, the budget was revised accordingly and was put up to cabinet for approval. The proposal was endorsed by 119th Lhengye Zhungtshog held on 22 November 2016 and the OH plan was launched for operationalization on 6 November 2017 with the signing of MOU between the key and collaborating stakeholders.

4.2 Update on One Health Activities from Public health sector: Dr Sonam Wangchuk, Royal Centre for Disease Control, Ministry of Health

The One Health approach acknowledges that population health is dependent on interactions between animal and human diseases. In a globalized world, humans and animals interact with greater frequency and intimacy which offers the opportunity for the emergence and spread of disease agents (chemicals, pathogens, etc.). This could adversely impact animal health, human health, or both which requires multidisciplinary approach to address. Bhutan has long history of practicing one health approach informally at technical level and formally embraced one health approach and developed “Bhutan One Health Strategy Plan” to proactive address

8 one health issues. The strategy was approved by the government in 2017 and MoU to implement one health strategy was signed among concerned stakeholders in the same year. Some key activities conducted by health sector: 1. Updated NIPPP for human health, developed strategy for elimination of rabies by 2023 and was updated, and developed National guideline for prevention, treatment and control of scrub typhus. 2. Develop laboratory capacity at RCDC to detect Brucella, Crimean Congo Hemorrhagic fever virus, Kyasanur Forest Disease Virus, Nipha virus (PCR), Hantavirus, Ebola virus and importantly validated and certified BSL- 3 laboratory. 3. Assessment of rabies burden and PPE seeking behaviour among exposed human and screening of blood samples from chronic failure cases for Hantavirus was conducted.

4.3 Update on One Health Activities from Animal health sector: Dr Tenzin, National Centre for Animal Health, Department of Livestock

The Animal Health sector have implemented various OH activities during the past three years and includes the following: 1) Disease Outbreaks Investigations, Containment and preparedness programme • Investigation & Containment of Rabies outbreaks in Trashigang, Panbang, Orong, Samtse, Phuentsholing, Gelephu, Lhamoizingkha and Samdrup Jongkhar • Investigation & Containment of HPAI outbreaks (12 outbreaks between 2010 and 2018) • Investigation & Containment of Anthrax outbreaks • Coordinated World Rabies Day events and cross-border mass dog vaccination campaign 2) Evaluation and assessment of disease control program and capacity • Evaluation of Rabies control program using SARE tool • Conducted National Stakeholder workshop on Brucellosis Control (18-19 June 2018) • Participated WHO-IHR JEE workshop (11-15 Dec 2017) Organized IHR-PVS National Bridging Workshop (13–15 March 2018) 3) Development of disease control plan and guidelines including rabies, srub typhus, HAPI, anthrax, AI communication strategy 4) Conducted OH Research • AST profile of Salmonella in human, animal and food survey (WHO-AGISAR Project) • Sero survey of Leptospirosis in human and animals (WHO supported)

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• Sero survey of Crimean Congo Haemorrhagic Fever (CCHF) virus in goats and cattle • Rabies health seeking behavior and PEP compliance study (WHO supported) • Rickettsia disease survey at human-animal interface • Detection of zoonotic pathogens from rodents in Gedu, Bhutan • Avian influenza survey • Survey of Echinococcus in dogs • Risk-based survey of brucellosis in dairy cattle • Feral pigeon disease survey • Ticks survey 4) Conducted training related to survey and diagnosis of zoonotic diseases • Tick identification training to the laboratory officials in collaboration with RCDC, NCAH and AFRIMS, Bangkok • Training /simulation of National Influenza Pandemic Preparedness and Response Plan • Training on brucellosis & rabies diagnosis • Training on GIS and GPS

4.4 Update on One Health Activities from Wildlife sector: Dr Kinley Choden, Nature Conservation Division, Department of Forests and Park Services

The wildlife sector implemented following activities as OH approaches:  Joint Disease outbreak investigation particularly with animal health sector  Joint development of protocol for feral/stray dog population management and wildlife disease surveillance o Surveillance conducted in the field and report submitted jointly by Gedu, Tashigang, Tsirang, S/Jongkhar, Dagana, Mongar, Pemagatshel Divisions and RMNP, SWS, JSWNP, BWS, JWS PAs o Environmental and wildlife samples submitted to NCAH, Serbithang  Participated in the joint development of Strategy for elimination of dog mediated rabies in Bhutan  Drafted Bhutan Wildlife Health Strategy (2019-2028) in collaboration with other relevant agencies

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4.5 Update on One Health Activities from Food safety sector: Dr Kinley Penjore, BAFRA

The BAFRA implemented following activities as OH approaches: Policy & Research Activities  National FMD Prevention & Control Plan  National Rabies Prevention & Control Plan  Developing Framework for stepwise approach for Brucellosis Control Program  OH approach in determining Antibiotic Susceptibility of Salmonella in human, animal & food  Food borne outbreak investigation  Training on Food borne disease outbreak investigation Diseases Outbreaks Investigation and Containment  Rabies outbreaks investigation and containment  Foot and mouth disease outbreak investigation and containment  Avian influenza outbreak investigation and containment Food Safety  Antimicrobial Residues in Imported pork  Eradication of Iodine Deficiency Disorder through test and provision of recommendations  Implementing mandatory food labelling for pre-packaged food  Participated in food/rice fortification process for prevention of diet/nutrient related deficiency diseases in human

4.6 Emerging and Re-emerging Infectious Diseases Scenario and Threat to BHUTAN: Dr Sonam Wangchuk, Royal Centre for Disease Control, Ministry of Health The incidence of emerging infectious diseases in humans has increased within the recent past or threatens to increase in the near future. Over 30 new infectious agents have been detected worldwide in the last three decades; 60 per cent of these are of zoonotic origin. Developing countries including Bhutan suffer disproportionately from the burden of infectious diseases given the confluence of existing environmental, socio-economic, and demographic factors. In the recent past, Bhutan has seen few outbreaks of re- emerging diseases of zoonotic origin. It is likely that Bhutan will see more number of emerging and re- emerging diseases of zoonotic origin because of its rich biodiversity and close interaction between human, domestic animals and wild life. Prevention and control of emerging infectious diseases will increasingly

11 require the application of sophisticated epidemiologic and molecular biologic technologies, changes in human behavior, a national policy on early detection of and rapid response to emerging infections and a plan of action. A comprehensive national strategy on infectious diseases cutting across all relevant sectors with emphasis on strengthened surveillance, rapid response, partnership building and research is needed to guide public policy.

4.7 South Asia One Health Disease Surveillance Network: Dr Sithar Dorjee, Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu, Bhutan

The world is experiencing increasing events of emerging and re-emerging infectious diseases, and about 70% of emerging infectious diseases (EID) originated in animals. Furthermore, increasing incidence of antimicrobial resistance (AMR) has been recognized as a serious public health and animal health threat. The challenges of EIDs and AMR require a One Health approach that supports a holistic, multisectoral, coordinated and collaborative network, not only at a country level but at a regional level. Several regional disease surveillance networks have been established in Southeast Asia, East Africa, South East Europe, Southern Africa, and Middle East, and recently in South Asia. The purpose of establishing South Asia One Health Disease Surveillance Network are inter alia, to facilitate coordination and strengthening of regional capacities for disease surveillance, rapid outbreak detection and response to controlling zoonoses and pandemics at best at a country or regional levels, support development of effective disease surveillance systems, create a common platform for timely sharing of disease information, coordinate and organize training on disease surveillance, outbreak investigation and laboratory diagnoses, and facilitate cross-sectoral and cross-border collaboration to address issues related to transboundary and zoonotic diseases. This presentation will provide the overview of the network; its vision, purpose and functions, progress thus far, opportunities and expected benefits of establishing this network through the support of ECTAD-FAO and Ending Pandemics of US.

Discussion and deliberation of the session The following issues and points were discussed and deliberated in this session:

 Floor requested the organizer to include rabies outbreak containment activities undertaken in Chukha & Samtse also in the implementation status of resolution 2 of 3rd One health conference.  On information sharing the house raised that current information sharing system amongst various stakeholders is insufficient citing that few are web-based and others manual. The chairman of the session advised organizers to take note of it and work on it to make uniform.

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 Floor enquired about the surveillance procedure in place to tackle outbreaks of zoonotic diseases like Japanese encephalitis in nearby Indian state to which presenter informed that they have syndromic surveillance system in place.  Dr. Yonten shared with the house that recent study has shown that almost all the ticks that are responsible for transmission of zoonotic diseases mentioned in the presentation are present in Bhutan up to genus level and team is working on species identification to ascertain the prevalence of the disease.  The floor submitted the suggestion on requirement of isolation chamber in JDWNRH and policy review on requirement of screening procedure against yellow fever for health official.  The floor suggested exploring other alternatives rather than forming group on social media. Dr. Sither shared with the floor that recent meeting at Bangkok resolved that FAO will fund to set up webpage for the OH office for information sharing. Dr. Passang Tshering recommended including OIE in this network. Identifying the need for a reliable platform to facilitate rapid and real time sharing of information, expertise and resources among the relevant stakeholders under the One Health umbrella, the floor resolved to develop a One Health webpage.  Need to appoint position holders in OH secretariat was also raised by the floor to which Director General of DMS informed that Minister shall be apprised about it first and then sort out the matter through inter-ministerial meeting  For the functioning of the impending OH secretariat, which is being currently pursued in the RCSC, the floor discussed and suggested that the chairpersonship of the secretariat should be rotated between the ministers: MoH and MoAF.  The floor commanded the numerous activities carried out jointly by different stakeholders which have resulted in publication of several research articles and reports. The accessibility to these reports were asked to which it was clarified that the plans are in pipeline to make them available on the webpage. Meanwhile, RCDC representative informed the floor that the articles and reports are available on their website.  The chairperson applauded the update, which was for the first time, on the One Health activities undertaken by the wildlife sector. Furthermore, she also applauded the effort brought about by BAFRA in initiating nutritional labelling of the food products which she said would have tremendous impact on reducing the non-communicable diseases (NCD).  The chairperson commanded the strengthening collaboration since the first workshop that was held in 2013. She stressed that to ensure the OH conference be conducted annually, there is need to allocate budget by the agencies.

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5 Session 3: Performance Evaluation of human and animal health services

5.1 Joint External Evaluations for IHR Core Capacities: Mrs Jamyang Chodon, Ministry of Health

The Joint External Evaluation (JEE) is a voluntary, collaborative process to assess country capacity under the International Health Regulations (IHR) (2005) to prevent, detect, and rapidly respond to public health threats whether occurring naturally or due to deliberate or accidental events. The JEE allows countries to identify the most urgent needs within their health security system, to prioritize opportunities for enhanced preparedness, response and action, and to engage with current and prospective donors and partners to target resources effectively. During the Bhutan's JEE mission in December 2017, capacities in 19 technical areas were evaluated through a peer-to-peer, collaborative process that brought National subject matter experts together with members of the JEE team in a week of collaborative discussion and field visits. This process led to consensus on scores and priority actions in 19 technical areas. The assessors concluded that Bhutan’s commitment to building and/or maintaining capacities to detect, assess, notify and respond to major public health events is genuine and strong. Three overarching recommendations emerged during the JEE mission, intended to address challenges affecting Bhutan’s capacities in a number of technical areas. These are:

1. Update IHR-related laws, regulations, guidelines and standard operating procedures to provide clarity on roles, responsibilities and lines of communication. Bhutan’s national legislation and policies have been revised in recent times to incorporate strengthening of IHR (2005) core capacities, and the government is working to enhance the workforce. While existing good practice should be noted, and collaboration across sectors generally functions well, it is also apparent that the implementation of these core capacities could be better defined. 2. Implement joint mechanisms through which professionals from different sectors can adopt the One Health approach. It was also noted that while Bhutan’s human and animal health sectors demonstrate progress and good practice, communication and collaboration between the two could be improved, with great consequent benefit for overall health security. 3. Establish a multisectoral comprehensive training and exercise programme to test, validate and enhance preparedness and response operations. Finally, it was noticed that Bhutan’s existing health security systems have not all been adequately validated and refined by a structured training and exercise programme.

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In addition to these overarching recommendations, the JEE team developed 3-5 priority actions for each technical area of the JEE.

5.2 Findings and recommendations of the OIE-PVS Evaluation: Dr Karma Rinzin, Department of Livestock

The World Organisation for Animal Health (OIE) fielded series of missions to carry out the evaluation of the performance of veterinary services in Bhutan. The first PVS mission was fielded in June 2008 followed by the Gap Analysis Mission in November 2009 and a follow-up mission in March 2015. The OIE PVS follow-up mission took place seven years after the first evaluation and six years after the PVS gap analysis designed for 2009-2014. Results show that notable improvement have been made in physical and human resources, as well in some activities. The 20 DVHs, four RLDCs, many Geog infrastructures, as well as NCAH and BAFRA central laboratories have been renovated and adequately equipped. The most important progress has been the recruitment of veterinarians at the district levels. BAFRA made significant progress in food safety, especially in meat shop hygiene. DRA has successfully started to regulate veterinary medicines and vaccines including national production of vaccines following the international standards. However, these investments cannot produce their full impact as long as major policies and strategies are defined. Staff are not given appropriate continuing education; specialised training in VPH has not been undertaken. Moreover, veterinarians cannot have a clear understanding of their roles if they are not defined properly between levels: strategic planning at the national level, operational planning at RLDC level, field activities at DVHs and Geog levels. In particular, fieldwork is still considered to be the task of veterinary para-professionals that veterinarians do not supervise effectively. In addition, the break in the chain of command, without proper external coordination, hampers the capability of the VS to implement national programs or to handle unexpected emergencies. Most recommendations made in the follow-up mission report were previously made in the 2008 OIE PVS evaluation and further detailed in the 2009 PVS gap analysis. Following the OIE follow-up mission and based on the request of Bhutan, OIE fielded Laboratory missions in January 2016 and Legislation mission in July 2018. The DoL and BAFRA is in the process of implementing the recommendations of OIE follow-up missions and other missions (Laboratory and Legislation). Besides in the 12th five year plan (FYP), DoL and BAFRA are focusing on the paradigm shift in the delivery of animal health and food safety services. The main strategies in the 12th FYP include: 1. Strengthen One Health and veterinary public health services 2. Enhance risk based disease prevention and control

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3. Strengthen laboratory diagnostic services 4. Promote professionalism and expertise in veterinary clinical services 5. Upscale cost recovery scheme for sustainable animal health services 6. Strengthen animal health research 7. Initiate herd health management services

5.3 Findings and Recommendations of National IHR-PVS Bridging Workshop: Dr Sithar Dorjee, Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu, Bhutan

The National IHR-PVS Bridging Workshop was held from 13-15 March 2018 at Paro. It was organized by WHO, OIE, MoH and MoAF. A total of 69 participants from MoH, MoAF, academic institutions participated in the workshop. The objectives of the workshop were to jointly review JEE and PVS evaluation findings and recommendations and identify options to improve coordination between sectors to strengthen preparedness, spread and control of zoonotic diseases. The expected outcomes of the workshop were to increase awareness and understanding on the IHR, IHRMEF, OIE PVS evaluation, improve understanding on how the results of the PVS evaluation and IHRMEF can be used to strengthen coordination and collaboration between the two sectors, develop joint roadmap for strategic planning and capacity building for advancing One Health in the country. This presentation will highlight the key findings and recommendations of the workshop such as level of collaboration between the sectors in 16 key IHR technical areas, key prioritization areas, development of harmonized and joint roadmap of key priority activities identified during JEE and PVS evaluation exercises with that of the National One Health Strategic Framework.

Discussion and deliberation of the session The following issues and points were discussed and deliberated in this session:

 Regarding the recommendations that were presented as the findings of the IHR-JEE, the floor asked what are the action plans to implement the recommendations. The presenter clarified that action plan has been developed and has been circulated to the relevant agencies. The implementation status will be followed up. To ensure that the findings of the IHR-JEE were followed up and implemented accordingly, one recommendation put forward by the presenter was to convene annual executive meeting regarding IHR.

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 The current trend of specialization among veterinarians in Bhutan has been in epidemiology and veterinary public health. Having presented the findings of the OIE-PVS evaluation on the need for an enhanced monitoring of para-veterinarians in the field, a concern was raised on how to balance the inclination of the veterinarians in specializing in para-clinical courses and the country’s need for clinical specialist given the void created by the current trend of specialization. The CVO informed the floor that the Department of Livestock has been striving to make linkages with the universities in Thailand to attract veterinarians to specialize in the mainstream veterinary clinical subjects. He also acknowledged that the Bachelor of Veterinary Science and Animal Husbandry (BVSc. & AH) degree conferred by the Indian Universities is not equated to Veterinary Medicine degree conferred by other universities in the world and this has been one of the stumbling block for veterinarians in Bhutan to avail opportunity to pursue higher studies in clinical subjects, which otherwise is relatively easy for non-clinical courses. 6 Session 4: Projects

6.1 One health approach to determine antimicrobial resistance profile in Salmonella isolates collected from human, animal and food samples: Dr RB Gurung, National Centre for Animal Health, Serbithang

Penicillin was discovered in 1928 by Alexander Fleming heralding the era of modern medicine. Thereafter several other antibiotics were discovered and used by human and veterinary health care systems. Over the time, it was found that many of the antibiotics in use have become ineffective in controlling infection. This was mainly due to resistance developed by microorganism against antibiotics that were normally used for treatment. Scientific communities for antimicrobial resistance were concerned about the extent that would significantly impact human and animal health. In 2017, World Health Organization-Advisory Group for Integrated Surveillance of Antimicrobial Resistance (WHO-AGISAR) identified Bhutan among several other countries to pilot a study on One Health Approach to determine Antibiotic Susceptibility Test (AST) profile of Salmonella organism isolated from human, animal and food samples. Subsequently, the human, animal and food sectors jointly conducted this study. In human sector, Royal Centre for Disease Control (RCDC) and Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) collected stool samples from hospital patients and outbreak areas. In animal sector, National Centre for Animal Health (NCAH) collected faecal samples from poultry. In food sector, National Food Testing Laboratory (NFTL) collected samples from various food and meat samples. Laboratories from all sectors used harmonized protocols for bacterial culture, identification and AST profiling. AST profiling was performed based on CLSI guidelines. Panel of antibiotics used were ampicillin, ceftriaxone,

17 ciprofloxacin, Sulfamethoxazole/trimethoprim, chloramphenicol and tetracycline. In total 49 isolates were recovered from 1261 samples: RCDC- 3.02% (15/496); JDWNRH-2% (6/300); NCAH-3.43% (12/350); and NFTL-13.91% (16/115). In animal sector majority of the isolates were resistant to ampicillin and sulfamethaxozole/TMP. The isolates were also resistant to tetracycline, another antibiotic extensively used in animal sector. In human sector, response to all six antibiotics was good. However, there were two isolates resistant to Ciprofloxacin, a quinolone group, which is a WHO priority antibiotic for Salmonella. Genetic characterization of these isolates may decipher the resistant determinant in them. In contrast to animal sector, sulfamethaxozole/TMP in human sector is still serving intended purpose. It is probably due to the decision that the human health sector made to stop its usage in the past and re- introduced. In food sector, isolates were resistant to chloramphenicol in addition to ampicillin and sulfamethaxozole/TMP. This indicated the concern to consider antibiotic usage in food producing animals.

6.2 An overview of Fleming Fund AMR project: Dr. Karma Rinzin, Department of Livestock

Antibiotics are used widely in human and animal medicine over decades. The antibiotics have saved millions of lives since they were first discovered. Antibiotics are used in animals for improving welfare and for enhancing the production. Our generation has benefited enormously from these important medicines. However, the indiscriminate use of antibiotics led to emergence of resistant bacteria in which antibiotics no longer work. No new classes of antibiotic have been discovered since the 1980s in contrast to emergence of new microorganisms (bacteria) each year. Resistant bacteria arising either in human, animals or environment may spread from one to another making AMR a one health issue and a global public goods.

The UK Government has established the Fleming Fund to respond to the global threat of drug-resistant infections, also known as antimicrobial resistance (AMR). The Fleming Fund is critical to achieving the resolution of the 68th World Health Assembly, 2015 (WHA A68/20); 84th World Animal Health Assembly (WAHA 2016); and in realising the ‘Political Declaration of the High-Level Meeting of the United Nation General Assembly (UNGA) on Antimicrobial Resistance, 2016’. The UK Department of Health and Social Care has appointed Mott MacDonald as the Fleming Fund Management Agent for the Fleming Fund Grants Programme. Mott MacDonald is a global company with expertise in multi- sectoral international development and fund management.

The aim of the Fleming Fund Grants Programme is to improve the ability of recipient countries to diagnose drug-resistant infections, with an emphasis on antibiotics, and improve data and surveillance,

18 to inform policy and practice at national and international levels. The overall goal is to avert the human and economic burden of AMR. The Fleming Fund Grants are provided to participating countries through three funding channels viz. Country Grant, Fleming Fellowship Scheme and Regional Grants.

Following the series of missions fielded by the Mott McDonald to Bhutan from January to June 2018, Bhutan submitted Request for Proposals (RFP) for the first Country Grant in July 2018 to address critical gaps in surveillance of antibiotic-resistant bacteria in Bhutan. The proposal was approved by the UK Department of Health and Social Care and project will kick start soon after signing of memorandum of understanding between the donor and the Royal Government of Bhutan. This first Fleming Fund Country Grant for Bhutan will focus on putting in place the foundations for antimicrobial resistance (AMR) and antimicrobial use (AMU) surveillance in the human and animal health sectors. It will facilitate a stronger One Health approach to surveillance bringing together multi- sectoral stakeholders to share surveillance data and gain a better understanding of AMR and AMU.

Discussion and deliberation of the session The following issues and points were discussed and deliberated in this session:  The floor commanded the hard work that NCAH and the collaborating agencies has invested in coming up with a very informative research on antimicrobials. To the clarification sought by the floor with regards to the rationale behind use of different break points for different antibiotics to determine resistance, Dr. Gurung informed that the break points were adopted as from the Clinical and Laboratory Standards Institute (CLSI) guidelines.  The floor was informed that the duration of the first phase of the Fleming project was two years and that ensuring infrastructural development such as laboratory and procurement of equipment within the timeline would fit in as one of the success indicators.  In the context of detecting resistance in a sample collected from the barn owl in Thimphu, the floor enquired if the impending Fleming Fund Project plan to collect and test samples from the wildlife, to which Dr. Gurung informed that the wildlife will also be covered in the coming up project.  To the question raised by the floor on drawing correlation among between the resistance pattern among the samples collected from diarrheal sample, animal sample and food sample, Dr. Gurung clarified there would not be any correlations made as the sample were collected from different locations.

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7 Session 5: AMR and Food safety

7.1 AMR surveillance in children under 5 years of age with diarrhoeal cases: Mr Tshering Dorji, Royal Centre for Disease Control Diarrhoea is a major cause of morbidity among the children under 5 years of age in Bhutan. Although it was reported as the second most reported disease for many years, study on causative agents and antimicrobial resistance of bacterial pathogens was never attempted. A case control study was conducted from 2011 to 2015 at the four major hospitals in the country. A total of 3100 children with diarrhea were enrolled for this study over the period of 5 years. Through this study it was determined that the major of cause of diarrhea among children under 5 years of age was due to viral enteric pathogens. However, significant proportion of diarrhea was also caused by several bacterial pathogens. Campylobacter, Salmonella, Shigella, Aeromonas and certain serotypes of E.coli were the bacterial agents, while Rotavirus and Norovirus were the viral agents significantly causing diarrhea mong the children. However, no pathogens were detected 29% of samples. This study also found that the bacterial pathogens are becoming resistant to most of the commonly used antimicrobial drugs used in the country. Therefore, Bhutan needs to closely monitor the antimicrobial resistance pattern in human, animal and food through surveillance and multisectoral collaboration to mitigate, prevent and control antibiotic resistance in the country. Further research needs to be conducted to understand other causes of diarrhea among the children in Bhutan.

7.2 Foodborne Disease Outbreak Investigation: A case study of One Health Approach: Dr Sithar Dorjee, Khesar Gyalpo University of Medical Sciences of Bhutan

Food safety is a growing public health concern worldwide and WHO estimated the global burden of foodborne diseases caused by 31 food hazards to 600 million illnesses (95% UI 420–960) and leading to 420,000 deaths (95% UI 310,000–600,000) in 2010. Many cases of foodborne diseases also go unreported in all countries. Food is one of the important medium for spread of pathogens including AMR organisms of significant public health. Increasing number of foodborne disease outbreaks are being reported in Bhutan, mainly in schools, mass gathering events, and from foods consumed in hotels, restaurants, and bakeries. However, there is no adequate foodborne disease surveillance system established yet in Bhutan. Food foodborne illnesses prevention and control are complex problems that require One Health approach, particularly between food safety authority and public health sector. In this presentation, the importance of One Health approach towards prevention, investigation and response management of

20 foodborne disease outbreaks will be highlighted using an example of sever foodborne illness that occurred in July 2017 in Thimphu. The suspected food foodborne illness was reported to the Royal Centre for Disease Control (RCDC) by medical doctor on 27 July 2017. The preliminary assessment of the event by the RCDC found out that the potential source of outbreak was related to the consumption of cakes at two birthday party events. Based on this hypothesis, a joint investigation by the RCDC and Bhutan Agriculture and Food Regulatory Authority (BAFRA) was conducted to identify the source of outbreak. The joint investigation later confirmed that the illness was caused by the consumption of birthday cakes bought from a bakery in Thimphu. The causative organism of the outbreak was Salmonella spp. RCDC and BAFRA jointly investigated and contained further outbreaks by implementing appropriate control measures at the food source.

7.3 Microbial load and prevalence of Salmonella in imported fresh beef at different points of meat handling: Mr Kaling Dorji, Bhutan Agriculture and Food Regulatory Authority, Thimphu

Introduction: Meat is one of the major source of food-borne diseases for humans especially when they are processed in unhygienic conditions. A large quantity of fresh beef are imported from the border towns of India which may be contaminated by range of pathogens including Salmonella spp. The study was conducted to assess the general microbial load and prevalence of Salmonella spp. in the imported fresh beef at 3 different meat handling points in Bhutan. Method: A total of 216 fresh beef samples of 50 grams were collected from 3 identified meat handling points from July to September 2011. The Total Plate Count and isolation of Salmonella were done as per the International Organization for Standardization (ISO 4833:2003 and ISO 6579:2002) methods respectively. The microbial load was performed from 81 randomly selected samples and Salmonella isolation in all the samples. Result: The general microbial load (log cfu/g) was higher in samples obtained at retail point (7.36 ± 0.09SD) followed by destination point (6.99 ± 0.17SD) and import point (6.66 ± 0.23SD) with significant differences among the groups (p=0.01). Overall, 9.7% (21/216) of the samples were positive for Salmonella with the samples from the retail point showing the highest prevalence (16.7 %) followed by destination point (8.3 %) and import point (4.2%). Prevalence of Salmonella was significantly different between the retail point and the import point (P<.05)

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Conclusion: The current slaughter processes, transportation and meat storage facilities of the retail shops favor growth and multiplication of the microbes. High microbial load and Salmonella contains are bound to pose serious public health problems if timely preventive measures are not employed.

7.4 Antibiotic resistance of Escherichia coli causing diarrhea; practices and factors influencing use of antibiotics in swine farms in central region of Thailand: Dr Narayan Pokhrel, Dzongkhag Veterinary Hospital, Pemagatshel

Antibiotics are extensively used in swine production to control different kind of diseases in the farms, extensive use of antibiotics in food producing animals enhance the risk of antibiotic resistance in the commensal bacteria of these animals. It is essential to understand the background of the swine farms, drug usage, practice and factors influencing use of antibiotics in swine farms. This study was conducted to investigate practices and factors influencing use of antibiotics in swine farms using questionnaire surveys among 90 pig farmers and laboratory investigation to determine antibiotic resistance for E. coli isolated causing diarrhea in pigs in Central Thailand (Ratchaburi, Nakhonpathom and Suphanburi). 176 E. coli isolates were tested for resistance and ESBL-production against 18 antibiotics by VITEK 2 system (Version 07.01, bioMerieux, USA). 88 out of 90 farms in the three provinces used eight classes of antibiotics on their farms for therapeutic and prophylaxis purposes. Majority of the farms used colistin (76%). 71 % of the farmers reported E. coli diarrhea on their farms, large quantity of antibiotic was used to treat respiratory disease as compared to other disease in the last two years. 52% of the farmers relied on experience to use antibiotics with no supervision of veterinary personnel and in 97% of the farms non-veterinary people administer antibiotic in animals. 91% of the farmers had easy access to antibiotics. Farmers with education equivalent to bachelor degree and above and farmers who had received awareness on AMR showed better knowledge on antibiotic use and antibiotic resistant as compared to farmers with less education and received no awareness on AMR. In laboratory study of antibiotic susceptibility testing of E. coli showed that there was a high prevalence of multi-drug resistance and ESB- producing E. coli isolates in the swine population. Multidrug resistance was seen for 99% of E. coli isolates. These findings call for a want of prompt actions on antibiotic overuse, antibiotic misuse and strict regulation on the use and access to antibiotics on piggery farms in Central Thailand.

Discussion and deliberation of the session The following issues and points were discussed and deliberated in this session:

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 To the query raised regarding the chances of selecting incorrect antibiotics for determining the sensitivity of a pathogen, the floor were clarified that such errors occurring is unlikely as the antibiotic selection for conducting sensitivity test are done based on the WHO guidelines.  The floor raised questions regarding the importance of the mean duration of diarrhoea and age groups in studying the diarrhoeal pathogens. The presenter clarified that the mean duration of diarrhoea is critical to be recorded as different pathogens have different disease course and similarly there are age specificity for different pathogens for which recording different age groups becomes important.  The presentation on the high rate of Salmonella detection in meat imported from India was alarming and the floor was informed that the best way forward would be to adopt risk-mitigation measures such as proper handling and cooking of meat besides the stringent regulatory measures that BAFRA enforce in transportation and handling at the meat vendor level.

8 Session 6: Zoonotic diseases

8.1 Emergence of Brucellosis in Bhutan: animal Brucellosis and human case report: Dr RB Gurung, National Centre for Animal Health, Serbithang

Brucellosis is a highly contagious disease of ungulates affecting multispecies. B abortus is predominantly found in bovines. It is a disease of breeding stock, with non-specific or limited symptoms, variable or often long incubation period. Congenital infection is a significant issue with abortion, still birth/premature births and variable proportion of aborting females. The organism survives in environment for a considerably long period of time. Source of infection is usually from milk, colostrum, semen, vaginal secretions and abortion materials. Transmission usually occurs through direct contact, introduction of infected animal and ingestion of contaminated materials. Globally, bovine Brucellosis is reported from Asia, Africa, Middle East and Latin America. In 2015, in Bhutan the National Centre for Animal Health conducted serosurveillance in government cattle farms to determine prevalence. Subsequent investigations were conducted in farms with high seropositive rates. In 2017, the Centre again conducted national level surveillance all 20 districts and all milk cooperatives. Relevant samples (serum, milk, abortion materials) were collected and tested using various laboratory tests (RBT, ELISA, CFT, Culture and PCR).

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Prevalence of Brucellosis in cattle farms was found to be 6.28% (30/478) with highest prevalence in National Jersey Breeding Centre (NJBC) (24.6%; (28/114). Current update on the status of Brucellosis at NJBC was: 36.92% (48/130) (RBT); 37.69% (48/130) (ELISA); 36.15% (47/130) (CFT) and 13.33% (6/45) (Culture and PCR). National prevalence of bovine Brucellosis was found to be 2% (21/1099) with infection in 10 districts with highest infection rate in Haa. The human laboratory also reported four cases of human Brucellosis from symptomatic cases. Based on the findings of bovine Brucellosis, significant policy changes were made in animal sector such as occupational health safety, approval for vaccination in animals and food safety intervention.

8.2 Status of Multi-drug resistant tuberculosis in the country (2014 – 2018): Mr Karchung Tshering, Royal Center for Disease Control

The National Tuberculosis Reference Laboratory (NTRL) under the Royal Center for Disease Control (RCDC) has been conducting drug resistant surveillance for tuberculosis (TB) since 2010 to monitor the proportion and trends in drug resistance among new and previously treated TB cases in the country for evidence based intervention and policy discussion to prevent and control the emergence of drug resistance. All cases of multi-drug resistant tuberculosis (MDR-TB) registered for treatment in three MDR-TB treatment centers between January 2014 to November 2018 were included to update the status of MDR-TB in the country. All the demographic and drug resistance information were collected from the online Tuberculosis Information and Surveillance System (TbISS). A total of 280 patients with MDR- TB were registered for treatment between January 2014 and November 2018. 97.86% (274/280) of the cases were laboratory confirmed while 2.14% (6/280) were treated as suspected MDR-TB cases after failure of Category II regimen. 67.86% (190/280) of MDR-TB were new cases and 32.14% (90/280) were among previously treated cases. Almost 80% of the MDR-TB cases were among the productive age group of 10 to 39 years and students constituting 27.86% (78/280) of the cases. MDR-TB cases were more among females (166/114) and 19.64% (55/280) of the cases were house wife. 40.36% (113/280) of the cases has been residing in Thimphu over the last five years followed by Phuntsholing (12.86%; 36/280) and Samdrup Jongkhar (5.71%; 16/280). Emergence of multi-drug resistant tuberculosis in particular increasing proportion among newly diagnosed case is a growing public health concern and a threat to TB control in the country. Immediate and appropriate policy interventions and infection control measures need to be put in place to reduce the spread of drug resistant strains into the general population.

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8.3 A Case-Control Study to Identify Risk Factors of Multi-Drug Resistance Tuberculosis (MDR-TB) among New Pulmonary TB Patients in Bhutan, 2018: Dr Tandin Zangpo & group, Dechencholing BHU-I, Ministry of Health, Thimphu

Introduction: Multi-Drug Resistant Tuberculosis (MDR-TB) is an emerging threat to TB control efforts and public health care Bhutan. According to Drug Surveillance Report by the RCDC 2017, 13% MDR- TB was reported among new pulmonary TB cases in Bhutan. Aim: To determine the risk factors of MDR-TB development among the new pulmonary positive TB in Bhutan, 2017. Method: In this unmatched case-control study, we recruited 46 new MDR-TB cases and 138 PTB (Pulmonary TB) controls (1:3 case-control ratio), sampled all across the country. Results: The major significant risk factors identified in our study were delay in diagnosis (OR=24.893, p=<0.001), poor ventilation (OR=3.564, p=0.023), history of contact with MDR-TB patients (OR=7.249, p=<0.001), participants who lived alone (OR=10.770, p=0.016), health staff unfriendliness (OR=9.631, p=0.004) and TB medicine unavailability (OR=16.533, p=0.024). We also found that increasing in age was protective or on the contrary, the risk was higher among younger age group (OR=0.940, p=0.005). Innovative contributions: Recommended the National TB Control Program to create MDR-TB awareness and screening by focusing on economically productive age groups. Reinforce Infection prevention and control (IPC) at all levels. Health workers should be sensitized on improved communication skills, patient counselling and over all patient management. The health care centres should ensure continuity of anti-TB drugs supply through proper planning and monitoring.

8.4 Acute Undifferentiated Febrile Illness surveillance: Preliminary finding of causing agents: Dr Sonam Wangchuk, Royal Center for Disease Control

Acute febrile illness is one of the most common reasons for seeking medical attention in Bhutan but there is limited information on the frequency of specific infections. Rickettsia (Orientia tsutsugamushi and Rickettsia typhi) was found as one of the common etiologies causing acute febrile illness and outbreaks. Few leptospirosis cases were also diagnosed in human, however, no studies have been conducted that attempt to determine the cause of acute undifferentiated febrile illness prospectively through an entire year in admitted or OPD patients. The Royal Center for Disease Control has conducted sentinel surveillance for past two years to determine etiologies among AUFI admitted patients. Among common etiologies, orienta tsutsugamushi is found to be the most common causative agents of AUFI followed by leptospira species and flavivirus (dengue virus chikungunya virus and Japanese encephalitis

25 virus). The proportion of those agents varies from place to place. The preliminary findings suggest more study need to be conducted especially on rickettsial and related infection including anaplasmosis and cat scratch disease that are vector and zoonotic origin.

8.5 Chronology of HPAI-H5N1 outbreak in Bhutan and genetic characterization of virus involved: Dr RB Gurung, National Centre for Animal Health, Serbithang

Highly Pathogenic Avian Influenza (HPAI)-H5N1 virus is a notorious combination of HA and NA subtypes that has impacted poultry and human since 1997. Until now, globally it has affected poultry industries in 23 countries with at least one outbreak and 16 countries with human cases. Bhutan reported first outbreak of HPAI-H5N1 in 2010. Ever since then Bhutan experienced 12 outbreaks in seven different years until 2018. This study included the chronological orders of HPAI-H5N1 outbreaks from 2010-2018 encompassing spatial and temporal distribution. The study also included pathotyping and genetic characterization of H5N1 virus involved in the outbreaks and determine its virulence and relation to viruses reported in the region, respectively. Majority of the outbreaks were reported from border towns or adjacent to border towns with India. The recent outbreak in 2018 was attributed to rescuing of birds destined for slaughter. This is an indication to strengthen biosecurity at ground crossings points in border towns. Given the small scale of poultry industry in Bhutan when compared to other developed nations, the impact so far due to outbreaks has not been at disaster scale. All the outbreaks were rapidly contained. Phylogenetically the virus HPAI-H5N1 involved in first outbreak in 2010 was assigned to clade 2.2.3 which is a close relative to A/Chicken/Bangladesh/CD-08(09)BL/-418/2009. Similarly, the virus from 2012, 2013 and 2015 outbreaks were assigned to clade 2.3.2.1a, a close relative of A/Water fowl/Bangladesh/31935/2011/2.3.2.1a. The virus from 2016 and 2018 outbreaks were also assigned to clade 2.3.2.1a, a close relative to A/Duck/Bangladesh/21909/2014. It was concluded that the HPAI-H5N1 viruses from Bhutan and Bangladesh outbreaks were common progenitor. Pathotyping of H5N1 virus revealed presence of repeated basic amino acids at HA protein cleavage sites that attributed to high pathogenicity.

Discussion and deliberation of the session The following issues and points were discussed and deliberated in this session:

 The floor raised question if the finding of sero-positivity to Leptospira spp. in human was associated with Kidney failure to which Dr. Sonam Wangchuk clarified that they have collected sample from patients with kidney issues, but they couldn’t find indication of leptospira however

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he acknowledged that the sample size was very low. He expressed his plan of doing a more organized study.  To the question asked regarding the detection of Mycobacterium bovis in the large number of human TB reported, the presenter informed the detection of M. bovis was very low. Of the 400 samples that were positive to TB, only one case was of M. bovis.  To the concern raised by the floor regarding the lack of information sharing upon detection of pathogens in the studies to the field hospital, Dr. Sonam Wangchuk informed the floor that information has been shared through quarterly disease bulletin.  To an issue raised regarding the requirement of re-registration of TB patients outside Thimphu, the floor was clarified that the database can be accessed from across the Bhutan and therefore, once the patient is out of Thimphu, there is no need to re-register.  Regarding the brucellosis cases presented in the NJBC, the floor raised their concern regarding the risk mitigation measures being applied to minimise the risk of spreading disease to other parts of Bhutan since Samtse NJBC being a nucleus breeding farm. To this Dr. Gurung informed the floor that the animals are screened before supplying and only the animals that test negative are allowed to move out of the farm.  A discussion was ensued regarding the decision of vaccinating cattle against Brucella over test and cull protocol. The floor enquired the rationale behind this decision to which Dr. Gurung responded informing that the decision was made during the National Brucellosis Workshop conducted at Paro between 18-19 June 2018. Some of the reasons that he provided were that culling was against the sentiments of the cattle owners, there were no slaughter house in Bhutan, and none of the cattle owners whose cattle tested positive to Brucella were willing to send their cattle to the slaughter house. He also mentioned that brucellosis prevention and control plan will be developed and implemented after understanding the real disease situation in the country.

9 Session 7: Diseases at human-animal-wildlife interface

9.1 Synantrophic rodents as reservoir of zoonotic pathogens in Bhutan: Dr Yoenten Phuentshok, National Centre for Animal Health

The number of acute undifferentiated febrile illness cases (AUFI) has been on the rise recently in Bhutan leading to mis-diagnosis and inadequate treatment. Bhutan, known for its rich biodiversity and strong

27 conservation policies and has more than 200 species of mammals, including approximately 80 rodent species. Rodents are the most speciose mammalian orders and are well known reservoirs and vectors of many emerging and re-emerging infectious diseases globally. However, little is known about their role inAUFI cases and zoonotic disease transmission in Bhutan. A cross-sectional study of zoonotic disease pathogens in rodents was performed in Chukha district, Bhutan where a high incidence of AUFI cases had been detected in people. Field collections of rodents were performed in 2016 and 2017. Rodents in and around houses and agricultural fields were trapped using live wire mesh traps and samples. Samples were tested by Polymerase Chain Reaction (PCR) for O. tsutsugamushi and other bacterial and rickettsial pathogens causing Bartonellosis, Borreliosis, human monocytic ehrlichiosis (HME), human granulocytic anaplasmosis (HGA), leptospirosis, and rickettsiosis. A phylogenetic analysis was performed on all rodent species captured and pathogens detected. Four out of the twelve rodents (33%) sampled in 2016 tested positive by PCR for a zoonotic pathogen. Anaplasmaphagocytophilum, Bartonella grahamii, and B. queenslandensis were identified for the first time in Bhutan. Leptospira interrogans was also detected for the first time from rodents in Bhutan. Our study shows that sampling even few rodents in Bhutan can provide important information about potential risks of rodent-borne zoonotic diseases. This is the first study conducted in Bhutan dwelling into the role of rodents in transmission and maintenance of zoonotic pathogens and more studies targeting a larger sample size, diverse species of rodents covering more localities, diverse landscapes and varying seasons.

9.2 Bat diversity in Bhutan – implications for emerging infectious disease control: Mr Sangay Tshering and Tshering Gyelpo, College of Natural Resources, Royal University of Bhutan, Lobeysa

We investigated bat diversity and richness in broadleaf and conifer dominated forest of south-western Bhutan. Fieldwork was carried out from July 2016 to April 2017 and from March to September 2018 using mist nets and scoop or hand nets. Main objective of the study was to document bat diversity and richness of specific species. We captured 171 bats of 14 species belonging to five families. The two species (Myotis siligorensis Horsfield, 1855 and Rhinolophus affinis Horsfield, 1823) accounted for almost 51.59% of the total capture. Species richness of bats differed depending on habitat types. Myotis siligorensis were captured more often from broadleaf dominated forest whereas Rhinolophus macrotis Blyth, 1844 and Rhinolophus affinis were more common around human habitation. The present study contributed five new records for the country increasing bat diversity record to 70 species. Earlier Bhutan

28 has 65 bat species documented which constitutes 33% of all mammal taxa of which nine species are megachiroptera or fruit bats and 56 species are microchiroptera belonging to 5 families. The most common group of bats in Bhutan is the evening bats (Vespertilionidae) with 34 species. Despite bats being the most advantageous flying mammals on earth, it has been cursed as an evil spirit and vilified as an ugly creature and dirty in many parts of the Himalayan region. In some other countries, bats are known for spreading infectious disease. In Bhutan, little is known about bats as there is a lack of appropriate baseline information on impacts of bats. To fill up this gap, detail study is required.

9.3 Ecology of Lyle’s Flying Fox (Pteropus lylei) at the bat-human interface in Cambodia: Dr Kinley Choden, Nature Conservation Division

Introduction: Three Pteropus species are thought to occur in Cambodia. All three are listed in Appendix II of CITES (convention on international trade in endangered species of wild fauna and flora, 2011) and considered Vulnerable – IUCN Red List (“The IUCN Red List of Threatened Species,” 2008). Pteropus species have been identified as the natural host for Nipah virus (NiV). NiV was initially isolated and identified in 1999 during an outbreak of encephalitis and respiratory illness in Malaysia and Singapore. Recurring outbreaks occur in Bangladesh. To improve understanding of NiV ecology and to elaborate the frequency and magnitude of fruit bat movements, satellite telemetry is a valuable tool used to assess abundance and long- range movements of P. vampyrus in Malaysia; to characterise the flying fox colonies; to study the roosting behaviour and habitat selection of P. giganteus and to study the foraging behaviour and landscape utilization of flying foxes. This can be used to develop appropriate host management strategies that maximize the conservation of bat populations and minimize the risk of disease outbreaks in domestic animals and humans. The objective of this study is to describe the interface between Pteropus lylei and human and their domestic animals in Koh Thom District, Kandal Province, Cambodia. Materials and methods: Study site: Wat Pichey, Sakor, Koh Thom District, Kandal Province. Study period: 18th April to17th May 2016. The collaring of the bats in two shifts: 9 bats from 18th to 21st April and 5 bats from 3rd to 6th May 2016; Bat Collaring: Mist nets on two sites at the roost for bat capture; Collar put on sedated bats after selection, fed and released Data collection: two weeks after each collaring; Spatial data and site characterization: mapped on Google Earth (version 7.1); Tree species visited by bats and ‘points of interest’ noted ~interview of villagers; Habitat use: three major categories of GPS points: roost locations, foraging and commuting locations; Foraging points: Residential area, plantation, agricultural lands (any cultivated land not included in “plantations” and “residential areas”), uncultivated areas and rivers; Spatial Analysis: Used adehabitat package in R software (Version 3.2.3) to calculate the MCP (Minimum Convex Polygon: smallest

29 possible convex polygon around location data) and sp package in R software to calculate the maximum linear distance travelled from the roost per night. Results: Movement patterns and flight distance: Maximum distance travelled per night ranges widely (6.88 to 105.14 km; average 28.3km); Site fidelity displayed by bats (returning to the same site from 3- 11 nights); All bats shared at least one and as many as eight foraging locations (average 3km from roost) with another bat; QGIS to analyze the trajectories of each bat and to generate heatmaps based on kernel density estimation. The density was calculated based on the number of points in a location, with larger numbers of clustered points resulting in larger values. Discussion: Our study bats mostly foraged in residential areas (53.7% of foraging locations), rather than in plantations (25.6%): The greater diversity of fruit typically found in backyards compared to plantations could possibly explain this; shows a particularly strong interface through residential backyards where potential contact between bats and humans is expected to be higher due to continuous human presence; some individuals also showed fidelity to foraging areas indicating repeat utilization once a food resource was located. Studies say this is more energy efficient strategy rather than random foraging; Further information on the use of fruit partially eaten by bats by local residents would help to characterize transmission risks and inform preventative actions; Research on palm sap collection in the area is needed to assess the risk associated with this potential transmission route; Movements to other roost sites are relatively frequent. visits to four other roosts including one 105 km from the study site were observed. These results are consistent with a regional circulation of different NiV strains in Southeast Asia suggested in previous studies; Our study group had a male bias, with only one female tagged with the GPS device. Other females caught were not included in the study as they were possibly pregnant or lactating during this season. Therefore, it remains unclear if the sexes differ in their foraging behavior; Also, similar study needs to to conducted at different times of the year to study their temporal behaviour and movement patterns; We deployed GPS devices on a limited number of individuals, preventing us from any generalization of the observed patterns at the population level. However, the results were consistent between the different individuals, and provided useful information on the movement and foraging ecology of P. lylei in Cambodia; Nine of the 14 GPS collars we deployed lasted for at least 10 nights (average 11.8 nights), and 80% of the data were valid; While our data represent a snapshot in time, they nonetheless illustrate the potential for foraging behavior to potentially facilitate NiV transmission to humans and domestic animals; To date, no transmission from P. lylei to human or animals has been recorded despite the circulation of NiV in this species in Cambodia and Thailand; Nevertheless, understanding the ecology of P. lylei may significantly improve our ability to target limited resources for interventions, and educational campaigns that discuss the risks of NiV to people and their domestic animals; Awareness and education for villagers regarding the ecological importance of flying foxes; their role in disease transmission; and prevention measures seems to be a primary need.

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Discussion and deliberation of the session The following issues and points were discussed and deliberated in this session:

 With regards to the presenter’s comment on bats being believed as a reservoir for rabies, the floor commented that the association of bat with rabies is not just a belief but a proven reality and appropriate PPE set should be worn while handling bats.  Given that the presenter works with the bats and captures them for identification, the floor expressed that such activity would be a great opportunity to screen for pathogens and would provide an area of collaboration among the DoL, DoPH and DoFPS. The floor were informed that a separate bat borne zoonosis research study is in plan in collaboration with scientist from Japan.  Sample size for the rodent study was questioned to which presenter acknowledged that the study had very small sample size nevertheless the team being able to isolate and record pathogens for the first time from such a small number of rodent was very significant.

10 Session 8: Community Perceptions and Practices

10.1 Determinants of Rabies PEP seeking and compliance behaviour – Hospital and commmuniy-based contact tracing survey: Dr Kinley Penjor and group, Dewthang Military Hospital, Ministry of Health

Dog bites are the main source of rabies infection and death in humans, contributing up to 99% of all cases. We conducted a contact-tracing study to evaluate the health seeking and treatment compliance behaviors of people following potential exposure to rabies in rabies endemic south Bhutan. The rabies post exposure prophylaxis (PEP) register was used to identify animal-exposed victims who had visited five hospitals in south Bhutan between January and March 2017. They were traced and further data were collected from them using a structured questionnaire. A snowballing technique was used to identify victims who did not seek PEP.The survey was conducted between April and June 2017. Logistic regression was performed to assess factors associated with PEP-seeking and compliance behavior by the victims. Of the 630 who reported to hospitals, 70% (444) of people could be traced and additional 8% (39) who did not seek PEP was identified through contact tracing. Therefore, a total of 483 people were interviewed. Seventy one percent (344/483) of exposure were due to animal bites of which 80% (365/455)

31 were considered to be provoked incidents. Common reasons for not seeking health care included assumptions that risks of infection were minor if bitten by an owned or vaccinated dog. The victims who are male (OR: 0.36; 95% CI: 0.16-0.77) and educated (OR: 0.41; 95% CI: 0.17-0.96) were less likely to seek PEP, while those that experienced unprovoked bite (OR: 5.10; 95% CI: 1.20-21.77) were more likely to seek PEP in the hospitals. Overall, 82% of the victims sought PEP from the hospitals within 24 hours after exposure. Eighty three percent completed the PEP course prescribed by the physician. The respondents living in urban areas (OR: 2.67; 95% CI: 1.34-5.30) were more likely to complete the prescribed PEP course than rural dwellers. In conclusion, there is high risk of rabies infection in southern Bhutan. It is critical to bridge knowledge gaps and dispel existing myths which will help to improve PEP seeking and compliance behavior of people exposed to rabies infection from animals. A risk-based advocacy program is necessary to prevent dog-mediated human rabies deaths.

10.2 One Health profile of local communities living within a protected area in Bhutan: Dr Kinley Choden, NCAD

A One health community-based study was conducted to assess the knowledge, attitudes and perceptions regarding health issues of local people depending on their proximity to protected areas in Bhutan. Two sub-districts were selected inside and outside Jigme Dorji National Park for comparison. Snowball sampling method was applied for participant selection. Data was collected through use of both qualitative and quantitative approaches involving individual interviews (n=61), 3 focus group discussions, personal observations and active participation in villagers’ activities. Key areas of enquiry included the awareness and perceptions of the role played by wildlife in the epidemiology of diseases in humans and their livestock, the implications on coexistence between local communities and protected areas and on the surveillance of disease outbreaks in human-livestock-wildlife interface areas. The study found that more than 90% of the respondents reported owning at least one livestock. In terms of veterinary health care services, animal owners found it was very easily accessible and the only concern was the need for additional staff (20%). Livestock living inside the Park were reported to share the same grazing area and water resources with wildlife more frequently than those living outside the Park. People were generally aware of livestock animals and wildlife sharing some diseases (55.2%), while very few were aware of possible disease transmission from animals to humans (11.7%). With regards to human healthcare, people considered that the access was generally easy in both areas. Benefits derived from the forest were reported to be higher for people living inside the Park. However, the damages from wildlife to crops and livestock were also reported to be higher inside the Park. The willingness of people to conserve wildlife species depended on their appreciation of aesthetics, of the level of damages that it

32 causes to their crops and livestock, and also on the religious belief that all animals are sentient beings that shouldn’t be harmed. People living outside the Park were less aware of whom to inform for wildlife rescue emergencies. People from outside the Park also believed that living inside the Park would be oppressive, although they believed that they would be healthier living closer to nature. The study highlights the need for awareness of zoonotic risks among communities living inside and at the periphery of protected area, and the need for community engagement and participation in dealing with health issues of human, livestock and wildlife.

10.3 Knowledge, Attitude, and Practice survey rabies among cattle owners in two districts of Bhutan: Dr Sangay Rinchen and group, Regional Livestock Development Centre, Tsimasham

Background Rabies is eliminated from the northern and central parts of Bhutan, but it remains endemic in the southern region that shares a porous border with India. Control programs are challenged by free cross- border movement of dogs. Annually around 17 cases of rabies in dogs are reported. Frequent spill-over infection from dogs to cattle and other livestock species poses serious threats to public health and economic sustainability. Materials and methods As part of an approach to prevent rabies in cattle, we conducted a Knowledge, Attitude, and Practice and risk perception survey among cattle owners in selected rabies endemic and non-endemic districts of Bhutan. 563 cattle owners were interviewed using a structured questionnaire. The data were managed in Epi Info version 7.0 and analysed using R. Descriptive statistics were used for analysing demographic characteristics, and the association analysis was conducted using multivariable logistic regression. Results 88% of participants had heard of rabies. Only 40% of the participants who had heard of rabies had adequate knowledge about rabies. Multivariable logistic regression analysis showed that residing in endemic areas and having seen a rabies case were significantly associated (α=0.05) with having adequate knowledge. 70% of the participants who had heard of rabies had a favourable attitude towards rabies prevention. Residing in non-endemic areas and having seen a rabies case were significantly associated (α=0.05) with having a favourable attitude. 51% of the participants reported rabies as a curable disease. 92% of participants reported disposing of a bovine carcass that had died of illness. However, 8% reported that they would either dress and sell the meat, dress for consumption, or sell the whole carcass. More

33 than 70% of the participants reported engaging in farm activities that could potentially expose them to rabies and other pathogens, although only 25% of the participants reported using personal protective equipment while undertaking these activities. Conclusion Despite a high level of awareness, we observed that there is a lack of comprehensive knowledge about rabies regarding hosts, transmission modes, the outcome of rabies infection, and health-seeking behaviours. Our study highlights the need to enhance and strengthen rabies education programs to address the knowledge gaps that have been identified.

Discussion and deliberation of the session The following issues and points were discussed and deliberated in this session:  Regarding the study site selection for the KAP study, a question was raised on why the eastern study area was considered rabies free when we have been experiencing outbreaks. The presenter clarifed that the study was designed before the outbreaks occurred in the eastern Bhutan. Before the rabies outbreak in 2016 in Trashigang, an eastern district of Bhutan, particularly Trashigang was considered free of rabies.

11 Session 9: Disease Prevention and control Strategies

11.1 Strategic framework for elimination of dog mediated rabies in Bhutan: Dr Tenzin, National Centre for Animal Health, Department of Livestock, Serbithang

Rabies cause approximately 59,000 human deaths annually globally, with the vast majority of deaths occurring in Africa (36.4%) and Asia (59.6%). Domestic dog is responsible for more than 99% of human rabies deaths in the world. Elimination of rabies in humans can be achieved by eliminating rabies in dogs and other reservoirs. Rabies in dogs can be eliminated through sustained mass vaccination, control of dog population and responsible pet ownership. Human rabies can be prevented through prompt administration of post-exposure prophylaxis (PEP) following rabid animal bites. Efficient and effective surveillance system is critical to detect cases in humans and animals. Adoption of an integrated One Health approach is important in the management of rabies prevention and control strategies.

Rabies is a notifiable disease in Bhutan. Rabies commonly occurs in the southern belt of Bhutan along the borders with India; however, isolated cases have been documented in the interior parts of the country,

34 as a result of incursion from bordering areas. Therefore, it is important to control the disease at the source and prevent endemic transmission in the country. As part of the global effort to eliminate rabies by 2030, Bhutan has been actively implementing various strategies to control and eliminate dog-mediated rabies in the country through One Health approach. Bhutan aims to achieve zero dog-mediated human rabies death by 2023.

Although cross-border rabies transmission is a challenge, dog-mediated human rabies elimination is feasible in the country. Bhutan has achieved drastic reduction of human rabies deaths over the decades to zero cases during 2017 and 2018. Self-assessment of national rabies prevention and control program was conducted on World Rabies Day i.e. 28 September 2017 through consultative workshop using Stepwise Approach towards Rabies Elimination (SARE) tool. The assessment indicated that Bhutan is in right track and is currently in Stage 3.5 with much of the activities being achieved. Therefore, this make a good case for Bhutan to work towards elimination of dog mediated human rabies by 2023 as part of 12th Five Year Plan program. However, the maintenance of rabies free status would require continuous implementation of various activities and enhance effective surveillance system to detect cases in both human and animals for early response. For instance, dog vaccination, rabies awareness and risk communication, making PEP accessible and building capacity for rabies diagnosis and surveillance are crucial and are the common activities from the beginning and across all stages of the elimination program. This “Strategic plan for elimination of dog-mediated human rabies in Bhutan” provides both input and performance based indicator activities to be implemented to eliminate rabies deaths in humans in Bhutan with following goal, objectives, strategies and organization set up to implement rabies elimination program in the country: Goal: To eliminate dog-mediated human rabies by 2023 and maintain freedom by 2030 in Bhutan Objectives 1. To enhance rabies prevention and control in dogs; 2. To provide timely access to post exposure prophylaxis to all human following exposure to rabies; 3. To reduce dog population at a manageable level and promote responsible pet ownership; 4. To enhance community engagement on rabies prevention and control through community awareness and education, and 5. To institute coordination and collaboration mechanism through One Health approach at all levels Guiding principles of the Strategic framework 1. Dog bites are the primary source of human rabies. Human rabies prevention is possible through mass dog vaccination, promotion of responsible pet ownership and dog population control programmes with a partnership approach (One Health approach).

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2. Dog bites are a medical urgency and thorough cleaning of a bite wound is an important step which needs to be promoted at the community level through advocacy, awareness and education. 3. Post-exposure rabies prophylaxis should be made easily accessible, affordable and available for those that require it. 4. Enhanced surveillance is the key for monitoring the progress of the control program

Strategies for Rabies elimination The following are the key strategies that will be implemented to achieve rabies elimination plan in Bhutan. 1. Organizational setup of rabies control 2. Prevention and control of rabies in dogs 3. Prevention of rabies in humans 4. Strengthen and enhance surveillance 5. Strengthen disease outbreak response 6. Conduct and promote operational research 7. Advocacy, communication and social mobilization 8. Enhance partnerships and coordination 9. Cross-border control 10. Resource mobilization

11.2 Strategy for prevention and control of zoonoses: Mr Rinzin Kinga Jamtsho, DoPH, MoH

We live in a region where animal and human populations live in ever-closer proximity, allowing cross species transmission of pathogens including viruses that has pandemic potential. In particular, the Asia- pacific region is known as the global hot spot for emerging infectious diseases and has witnessed several outbreaks of high impact diseases such as avian influenza, Middle East respiratory syndrome Coronavirus (MERS-COV), dengue, Zika virus including recent Nipah Virus Outbreak in Kerala, India from April to May 2018. In Bhutan, Scrub Typhus and Leptospirosis are one of the main causes of acute febrile illness with many cases reported from southern and central districts of Bhutan. To date, 13 outbreaks of Avain influenza (H5N1) have been recorded in poultry and an average of 17 Rabies outbreaks in animals annually with the annual prevalence of 7,000 dog bites in human. Furthermore, prevalence of parasitic zoonotic diseases such as echinococcosis, cysticercosis and trematodes is unknown although Neurocysticercosis (NCC) is associated with 6% to 25% of epilepsy in a cohort from Bhutan. Furthermore, the presence of newer

36 threats such as environmental, chemical and radiological emergencies as well as uncommon patterns of antimicrobial resistance (AMR) add to our regional vulnerability. Particularly, Bhutan faces significant ant risk from zoonotic diseases due to: (i) increasing demand for livestock products, (ii) growing number of intensive livestock and poultry farms, (iii) ease and increasing movements of animal or animal products both within the country and through imports, and (iv) increasing movement of humans. This has presented a significant challenge in terms of the technical capacity, budgetary requirements and other resources for prevention and control of zoonoses. Therefore, Prevention and control of zoonoses will increasingly require the application of sophisticated epidemiologic and molecular biologic technologies, changes in human behavior, a national policy on early detection of and rapid response to emerging infections and a plan of action. A comprehensive programmatic strategy for prevention and control of zoonoses in addition to the Bhutan One Health Strategic Plan 2017-21 needs to be developed.

11.3 Bhutan Wildlife Health Strategy: 2019 – 2028: Dr Kinley Choden, NCD

The main rationale behind developing Bhutan Wildlife Health Strategy are because of wildlife and wildlife diseases impact on human health, livestock health on biodiversity and species conservation since “wildlife disease monitoring, prevention and control are crucial factors for safeguarding biodiversity and public and animal health worldwide –World Animal Health Organization (OIE)”. The draft document contain the following:

Vision: A comprehensive and effective wildlife health program contributing towards conservation of biodiversity, protection of health and life of humans and animals, and ensure sustainable livelihood. Scope: This strategic documents is limited to management of wildlife health, research and diseases that have potential to spread at human-domestic animals-wildlife interface

Objectives:  To institute and mainstream wildlife health program in the country;  To establish wildlife diseases surveillance program to detect emerging and novel infectious diseases, including zoonoses  To strengthen human resources capacity for wildlife health programs  To establish and strengthen wildlife disease outbreak preparedness and response capacity

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 To implement one health approach in prevention and control of infectious diseases at the human- domestic animal-wildlife interface  To promote collaborative research on conservation medicine, wildlife health, ecology and rehabilitation  To promote awareness and education on wildlife health and diseases  To strengthen institutional linkages at the national, regional and international levels  To mobilize resources to strengthen wildlife health programs

Startegic framework Strategic goal 1: Establish and strengthen wildlife health facilities Strategy 1.1: Develop Wildlife health policy and enabling instruments for functioning of Wildlife Health facilities Strategy 1.2: Institute wildlife health centersat strategic locations Strategy 1.3: Strengthen HR capacity of wil dlife health professionals

Strategic goal 2: Establish wildlife disease surveillance system Strategy 2.1: Institute a wildlife disease information management system Strategy 2.2: Generate profile of important wildlife diseases Strategy 2.3: Establish early detection of wildlife diseases and pathogens Strategy 2.4: Strengthen HR capacity for wildlife disease or pathogen surveillance

Strategic goal 3: Strengthen wildlife diseases preparedness, response and recovery system Strategy 3.1: Prevention of new wild animal pathogens introduction and its associated events Strategy 3.2: Establish effective wildlife disease preparedness and response system Strategy 3.3: Strengthen human resource capacity to prevent and responds to wildlife disease outbreak Strategy 3.4: Wildlife disease outbreak recovery plan and operations system

Strategic goal 4: Promote research and knowledge on wildlife health Strategy 4.1: Establish and institutionalize wildlife health research Strategy 4.2: Strengthen wildlife health research capacity Strategy 4.3: Establish priority wildlife disease mapping Strategy 4.4: Detection of wildlife disease in sentinel species Strategy 4.5: Establish wildlife bio-repository and natural history museum

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Strategy 4.6: Establish disease reservoir capacity in wildlife species

Strategic Goal 5: Resource mobilization Strategy 5.1: Secure financial resources Strategy 5.2: Pursue internal support for human resource, technical facilities

Strategic Goal 6: Develop and strengthen liaison and collaborations with international and local partners Strategy 6.1: Develop and strengthen collaboration amongst key national stakeholders Strategy 6.2: Initiate and establish collaboration with international organizations

Strategic Goal 7: Strengthen advocacy and communication on wildlife health Strategy 7.1: Efficient and effective management of communication at every level Strategy 7.2: Increase awareness on wildlife health and diseases to the policy makers, Ministry of Agriculture and Forests officials and other stakeholders

11.4 Animal welfare with focus on dog population management in Bhutan: Dr Karma Rinzin, Department of Livestock.

Animals have always been an important part of Bhutanese culture and have helped contribute to the socioeconomic development of the country, whether it be through the production of food and fibre, draft power, transportation or as part of the country’s cultural identity. More recently in the larger urban areas, companion animal ownership of dogs and cats is becoming an increasingly common trend.

Good animal welfare requires not only the combination of good nutrition, good health, suitable living environment, good handling practices and a humane slaughter or death, but also the ability of the animal to express natural behaviours. Animal welfare thinking these days is now moving beyond the traditional ‘Five Freedoms’ which focused on the absence or minimization of negative states (e.g. hunger, fear, disease, pain), towards recognition of the importance in also providing opportunity for the animal to experience positive experiences such as comfort, pleasure, stimulation and satisfaction.

The DoL and BAFRA developed Bhutan Animal Welfare Standards and Guidelines for different types of animals such as dairy, piggery, poultry, working and companion animals by covering all aspects of animal welfare. This standard and guideline should be considered in conjunction with Chapter IX and other relevant Chapters and sections of the Livestock Rules and Regulations of Bhutan 2017, relevant guidelines and specific disease prevention and control plans.

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Considering the number of problems associated with increasing free-roaming dogs in Bhutan, several control measures have been attempted since 1970s to control rabies and reduce dog population in Bhutan. This include shooting and poisoning in 1970’s and early 1980’s; translocation in 1990’s; and impounding in mid 2000’s. The past control measures were not successful due to number of animal welfare issues and poor acceptance of the Bhutanese people. In 2009, the Department of Livestock, Royal Government of Bhutan and Humane Society International (HSI), USA embarked on a long term project titled the “National Dog Population Management and Rabies Control Programme in Bhutan” (NDPM & RCP). Through this project the capture-neuter-vaccinate-release (CNVR) programme has been carried out with dogs being captured, neutered, vaccinated and released back to their place of origin. From 2014 onwards community animal birth control was initiated with the aim to involve the local communities and relevant stakeholders. As of December 2018 about 95,000 dogs were sterilized and vaccinated covering all the districts.

The DoL in consultation with other stakeholders developed National Dog Population Management Guidelines. This guidelines aims to formally institute and mainstream dog population management (DPM) in the country; encourage community engagement; create conducive policy and legislation framework for DPM; reinforcing CNVR program; and continuous monitoring and evaluation of the DPM program. Through implementation of these strategies we aim to improve the welfare of dogs; reduce the dog population to acceptable and manageable level; and achieve zero dog mediated human death due to rabies by 2023.

Discussion and deliberation of the session The following issues and points were discussed and deliberated in this session:

 The floor raised issues regarding the challenges faced in implementing the National Influenza Preparedness Plan (NIPPP) during the events of bird flu outbreaks. Further, as the current version of NIPPP was last revised in 2014, a need was felt to revise the document by incorporating short-comings and experiences learnt so far. In this regard the floor resolved that a technical working to be formed and incorporate the changes as amendment in the existing the NIPPP document.  Integrated Bite Case Management (IBCM) was discussed as an important option that Bhutan should adopt to achieve the goal of eliminating dog-mediated human rabies. In this regard, the

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floor decided to form a technical group to frame pragmatic IBCM modalities for implementing IBCM in the country.

12 Session 10: Group work and plenary presentation

Dr Pasang Tshering facilitated the group work session. During the world café session, the participants were broken down into four groups. Each group were assigned to work on few of the selected topics presented below in the table At the end of the group exercises, a plenary presentation was done to present the outcome of the discussion. Station A Station B Station C Station D Facilitator-Dr Sithar Dr Sonam Wangchuk Dr Tenzin Mr Rinzin K Dorjee Jamtsho  Institutionalization  Identification and  Identification  Strengthening of one health at prioritization of one health of priority one of every levels activities for implementation health research collaboration  Strategy for  Inventory of expertise related for and sustainable to implementation networking funding for one zoonosis/OH/Epidemiology/  Sustainable health activities lab capacity education on one health in the institutions First round-30 1. Appoint a rapporteur for each Group who populates the outputs on minutes a flip chart. He/she stays at the first station and finalizes the final Rotation between outputs stations after every 2. After the station rotation is complete the groups will return to the 15 minutes each first station and refine the outputs. Refinement of outputs – 15-30 minutes 14:00- 15:00 Plenary session of World Café: 15 minutes for each station group.

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Group findings

Group A: Institutionalizing of OH at Every Level & Sustainable funding

District OH Committee • Dasho Dzongda, Chair • DVO • DLO • CMO/MS • CFO • OIC, BAFRA • Thromdey Representative • Disaster Focal Person • SP/OC, RBP • Member secretary: DHO/DLO Additional Members proposed by other groups: • Immigration, Armed Forces, Point of entry OIC • DYT Chairperson • Open invitation for academia • Technical staff of regional offices (Livestock and Hospital) Thromdey OH Committee • Dasho Thrompon, Chair • MS/CMO • TVO

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• CFO • TEO • OIC, BAFRA • Disaster Focal Person • SP/OC, RBP • Member secretary: TVO/DHO Additional Members proposed by other groups: • Suggest to include Thromdey Health Officer as and when appointed • Establishment of Dungkhag and Gewog OH Committee need to assessed after 5-10 years • TOR for the committees needs to be developed Sustainable Funding for OH • Permanent OH Secretariat (upon approval): RGoB will fund the Maintenance and Operational Cost • Initial Set up by Fleming Fund • OH Secretariat will mobilize funds for Conferences (possible donors are WHO, OIE, FAO, NGOs etc.) • Funding for District/Thromdey Level Meetings: Dzongkhag annual budget (Member secretary will ensure incorporation of the budget)/OH Secretariat will mobilize • Collaborative Research: Fund mobilization by OH Secretariat/Sectors while research might be carried out by Technical agencies initially…. • OH Contingency Funding/Emergency Funding……???? Proposal: Disaster management and specific sector • OH Advocacy and Awareness: Take Advantage of sectoral specific meetings, sharing and pooling of funds Group B: Priority OH activities National Level • Develop plan for resource mobilization

• Capacity building for field staffs on surveillance and outbreak management

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• Advocacy on guidelines, SOP and strategies related to zoonoses

• Develop Information sharing mechanism at national level and district level

• Annual OH conference

• Institution of OH secretariat (

• Quality assurance system for surveillance and laboratory system

• Monitoring and Evaluation Regional/District level • Develop capacity to conduct disease outbreak and response for priority zoonoses

• Advocacy on priority zoonoses

• Disease surveillance on priority zoonoses

• Develop plan for resource mobilization at district level

• Information sharing mechanism at District and Geog level

• Establishment of OH core-group at district, Thromdey and Geog level Inventory of expertise: Laboratory and Epidemiology in the country Health Animal Health Food safety Wildlife Laboratory capacities (Diagnostics)

Brucellosis, Brucellosis, rabies, Salmonellosis, Basic diet and scat Salmonella, salmonellosis, HPAI, Enterobacteriacae, analysis, DNA Leptospirosis, scrub leptospirosis, Biosafety extraction(UWICE), typhus, murine shigellosis, anthrax, (GMO/LMO), parasitology (Taba),

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typhus, parasitology, AMR, mycotoxin, pesticides campylobacter, BSL-2+ and antibiotics, heavy shigellosis, KFD, metals CCHF, MersCoV, Ebola, Nipah, AI, E.coli,parasitology, AMR, BSL-3. Epidemiology capacity Epidemiologists, Epidemiologist, Food tech, Laboratory Epidemiologist, Laboratory tech, Microbiologist, tech, Microbiologist, Veterinary OH, dart virologist, Laboratory tech, Biotechnologist, specialists, Microbiologist, Pathologist, Chemists, Veterinary veterinarians, wildlife Immunologists, Parasitologists, OH. biologist Medical Doctor (OH), Veterinary OH. QA Specialist

Group C: Identification of priority OH research for implementation

• Economic analysis to demonstrate cost effectiveness of OH approach (using rabies as priority disease) • AMR (surveillance on human and animal) • Neglected tropical disease (taenesis and echninococcus, kala azar) • Bat borne zoonoses – Prevalence study • Snake species (poisonous and non-poisonous) and geographic distribution • Brucellosis at human/ animal interface • Rodent borne zoonoses • Tick borne diseases (impact on human health) • Risk factor on HPAI outbreaks in poultry • Bovine TB (Zoonotic TB) • Leptospirosis (Risk factors and disease profile)

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• Vector borne disease (dengue) – risk factors • Animal/human value chain studies (value chain analysis-joint assessment) • Community KAP and Risk mapping of scrub typhus • Anthrax – risk mapping • Impact of landfill waste on health – Human, animal and environment • Study on plant diseases impacting human and animal health • Surveillance of pesticides and chemical residue in food and meat, fruits and vegetables and dairy products • Survey of Infectious diseases that threaten conservation of fauna (rabies, canine distemper) • Impact of climate change on human and animal health • Impact assessment of rice fortification

Sustainable education on OH in the institution • Proposal on OH concept to be included in the school education • Develop curriculum/module on OH • Capacity development to educators • FETP-V • Invitation of guest lecture and speaker form different departments • Continuing Education on OH • Introduce online OH course (MOOC) • Institutional linkages with regional and international OH bodies • Develop social media platform for educating OH • Include OH in conference and scientific session by institution • Introduce OH Masters/ PhD program • Research on OH topic to be given to the students • Education and awareness on OH on Monk bodies

Station D: Strengthening OH collaboration and networking

At Central Level

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• Conduct Regular Meetings (at least once a year) • Create Social media groups (wechat, facebook, skype, teleconference etc.,) • Establish efficient real-time OH disease information sharing system hosted under OHS (OHS website) • Conduct/ organize national OH conference (annually/ biannually) • Resource sharing mechanism (financial, HR, technical) • Allocate certain fund/ budget for implementation of OH activities by all stakeholders • Conduct collaborative researches (MoH, Livestock, BAFRA, Wildlife, environment, CNR etc) • Seek high level/ government support • Provide update/ briefing to executive officials of all relevant stakeholders • Provide platform for OH socialization • Establish efficient linkage and coordination between central and district levels District level • Introduce and advocate OH concept • Establish OH core group • Carry out joint disease outbreak investigation at district as well as LG levels • Create social media groups • Conduct annual OH meeting in coordination with regional offices • Conduct joint CME and CVE annually • Resource sharing mechanism (financial, HR, technical) • Involve LG and thromde officials for all OH activities • Conduct joint advocacy and awareness in communities and institutions/ schools etc. • Conduct collaborative researches • Awareness on OH in MSTF and CBSS

13 Session 11: Closing session

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13.1 Conference Resolutions: Dr. Sangay Rinchen, Chief Rapporteur The following resolutions were presented and adopted during the conference:

Resolution #1: Identifying the need for a reliable platform to facilitate efficient and real time sharing of information, expertise and resources among the relevant stakeholders under the One Health umbrella, the floor resolved to develop a One Health webpage. Action: DoL and DoPH Resolution #2: To ensure that there is a uniform and sustained implementation of One Health activities at national and district level, the floor resolved to establish One Health committees at the district and national levels. The conference also recommended that the technical working group will be constituted at the National level immediately and should draft the following terms of references and prioritise the research activities:  TOR for national, district and Thromde level committees.  SOP for information sharing at every level  List of priority research activities to be undertaken immediately during 12th FYP and designating the lead agencies  Mapping of experts in all relevant sectors and institutions Action: DoL and DoPH Resolution #3: The floor raised issues regarding the challenges faced in implementing the animal health National Influenza Preparedness Plan (NIPPP) during the events of bird flu outbreaks. Further, as the current version of NIPPP was last revised in 2014, a need was felt to revise the document by incorporating short-comings and experiences learnt so far. In this regard the floor resolved that a technical working group comprising from the relevant agencies should be formed to incorporate the changes as amendment in the existing NIPPP document. Action: DoL and BAFRA Resolution #4: Integrated Bite Case Management (IBCM) was discussed as an important option that Bhutan should adopt to achieve the goal of eliminating dog-mediated human rabies. In this regard, the floor decided to form a technical working group to frame pragmatic IBCM modalities for implementation in the country. Action: DoPH and DoL Resolution #5: The institutionalization and establishment of OH secretariat is currently being pursued in the RCSC. In the event of the proposal not getting through RCSC, the floor recommended the OH technical working group to come up with an alternative model to continue the ongoing OH program. Action: DoPH and DoL

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Resolution #6: Having recognized the importance of carrying out OH activities, the floor deliberated on the importance of designating the Chair of IMCOH in line with National One Health Strategy Plan. In this regard, the floor recommended that IMCOH meeting be convened to designate the Chair and lead agency for the next One year. Action: DoPH and DoL

Resolution #7: The floor recommended that to facilitate and formalize collaborative food safety investigation procedure, the DoPH and BAFRA discuss and sign agreement on the existing draft Food Safety Investigation Protocol. Action: BAFRA, RCDC and DoPH

Resolution #8: In order to sustain One Health capacity building through continued education, it was recommended that Khesar Gyalpo University of Medical Sciences of Bhutan start One Health Field Epidemiology Training Program as soon as possible. Action: KGUMSB

Closing remarks Dr. Tashi Samdup, Director General, DoL, MoAF, expressed his happiness and commanded the diversity of the audience, presentations, and a well thought conference agenda. The Director General remarked that conference of this sort was unique and first of its kind. He expressed his appreciations to the conference organizer – Department of Livestock and Department of Public Health and other officials working behind the scene for a wonderful organization of the conference. He also expressed his appreciations to the presenters and the rapporteurs. He also thanked the WHO for providing fund support to organize this conference.

Dr Karma Lhazeen, Director, Department of Public Health thanked Director General, DoL for attending and guiding the entire sessions of the conference. She expressed her regrets for not being able to attend the presentations, despite her willingness, due to some unavoidable circumstances. She thanked the WHO for providing fund support to organize this conference. She made a remark that the collaboration and mechanism to combat zoonotic diseases have grown stronger with every passing workshop. Further, from this workshop resolutions she expressed her hopes that the collaborations among the different stakeholders will be strengthened. In line with the control of zoonotic diseases, the Director expressed her thoughts of Department of Livestock being operationally stronger and mature. Nevertheless, she informed the floor that the Ministry of Health is developing at rapid rate. Talking about rabies, she raised her concern about the increasing dog bite cases. With the Integrated Bite Case Management (IBCM) to

49 be implemented in the country, she expressed her hopes in reducing the use of Post-exposure prophylaxis. Furthermore, she asserted that there should be a sustained collaboration among various stakeholders. Lastly, she acknowledged the organizers, facilitators, presenters, rapporteurs, and officials working behind the scene in successful organization of the conference. She committed her support in combating the emerging and re-emerging diseases. She informed the floor that she had briefed the Health Minister about the One Health strategy plan. She closed her remark with the quote, “All is well that ends well”

14 Annex

14.1 Annex 1: Conference Agenda

4th National One Health Conference “Enhancing national health security through one health approach” Venue: Namsay Choeling Resort, Paro Date: 19 to 21 December 2018 Conference Programme Time Program Responsibility Day 1: Session 1: Opening Ceremony 8:45-9:15 Registration of participants NCAH 9:15 - 10:15 Welcome address Dr. Karma Rinzin, CVO, AHD Address by MoH Dr. Pandup Tshering, DG, DMS Address by MoAF Dr. Tashi Samdup, DG, DoL Vote of thanks Mr. Rinxin Jamtsho, CPO, CDD 10.15 – 10.45 Photo session and Refreshment Day 1: Session 2: Update on One heallth activities Chairman: Dr. Tashi Samdup, DG, DoL 10:45-10:50 Adoption of agenda Dr. Tenzin, NCAH 10:50 -11:10 Follow up of 3rd National One Health Conference Rinzin Kinga Jamtsho, PO, DoPH, MoH 11:10-12:00 Update on One health activities

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- Human Health Dr. Soanm Wangchuk, RCDC - Animal Health Dr. Tenzin, NCAH Dr. Kinley Choden, NCD - Wildlife Health Ms Kinley Penjore, BAFRA - Food safety 12:00-12:40 Update on the emerging and re-emerging infectious Dr. Sonam Wangchuk, RCDC diseases 12:40-13:00 South Asia One Health Disease Surveillance Network Dr. Sithar Dorjee, KGUMSB 13:00-14:00 Lunch Break Day 1: Session 3: Performance evaluation of human and animal health services Chairman: Dr. Karma Lhazeen, Director, DoPH 14.00 – 14.20 Findings and recommendations of the WHO IHR Joint Jamyang Choden, DMS External Evaluation 14.20 – 14.40 Findings and recommendations of the OIE-PVS Dr. Karma Rinzin, AHD, DoL Evaluation 14.40 – 15.00 Findings and recommendations of National IHR-PVS Dr. Sithar Dorji, KGUMSB Bridging Workshop 15:00-15:30 Tea Break Day 1: Session 4: Projects Chairman: Dr. Pandup Tshering, DG, DMS 15.30 – 16.00 One Health Approach to determine AST profile of Dr. R.B. Gurung, NCAH Salmonella in human, animal and food: Study supported by WHO-AGISAR Project 16.00 – 16.30 An overview of Fleming Fund AMR project Dr Karma Rinzin, DoL 16:30-17:00 General discussion and recommendations

Day 2: Session 5: AMR and Food safety Moderator: Dr. Sonam Wagchuk, RCDC 9:00 - 9:20 AMR surveillance on bacterial pathogens isolated from Tshering Dorji, RCDC diarrhoeal cases among children under 5 years 9:20 - 9:40 Foodborne disease outbreak investigatio: A case study of Dr. Sithar Dorji, KGUMSB One Health approach 9.40 – 10.00 Microbial load and prevalence of Salmonella in imported Kaling Dorji, BAFRA fresh beef at different point of meat handling in Bhutan

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10:00-10:20 Antibiotics resistance of E. Coli causing diarrhoea in pigs Dr. Narayan Pokreal, DVH, in Thailand Pemagatshel 10:00-10.40 Panel discussion 10:40 - 11:00 Tea Break Day 2: Session 6: Zoonotic Diseases Moderator: Dr. Karma Rinzin, DoL 11.00 – 11.20 Emergence of Brucellosis in Bhutan: Animal Brucellosis Dr. RB Gurung, NCAH and Human Case Report 11.20 – 11.40 Status of Multi Drug Resistant Tuberculosis (MDR-TB) Karchung Tshering, RCDC in the country 11.40-12.00 Risk Factors of MDR-TB among newly diagnosed Dr. Tandin Zangpo, DoPH Pulmonary TB in Bhutan – A Case Control Study 12.00 – 12.20 Acute undifferentiated febrile illness surveillance: Dr. Sonam Wangchuk, RCDC Preliminary findings of causative agents 12.20 – 12.40 Chronology of HPAI H5N1 outbreak in Bhutan and its Dr. RB Gurung, NCAH genetic characterization 12.40 – 13.00 Panel dicussion 13.00 – 14.00 Lunch Break Day 2: Session 7: Diseases at human-animal-wildlife interface Moderator: Dr. Sithar Dorjee, KGUMSB 14.00 – 14.20 Synantrophic rodents as reservoir of zoonotic pathogens Dr. Yoenten Phuentshok, NCAH in Bhutan 14.20 – 14.40 Bat diversity in Bhutan – implications for emerging Mr Sangay Tshering, CNR infectious disease control 14.40 – 15.00 Ecology of Lyle’s Flying Fox (Pteropus lylei) at the bat- Dr. Kinley Choden, NCD human interface in Cambodia 15.00 – 15.20 Panel discussion 15:20-15:40 Tea Break Day 2: Session 8: Community Perceptions and Practices Moderator: Dr. R.B. Gurung, NCAH 15.40-16:00 Rabies PEP seeking and compliance behaviour – Dr. Kinley Penjor, MoH Hospital and commmuniy-based contact tracing survey 16.00 – 16.20 One health profile of local communities within and Dr. Kinley Choden, NCD outside a protected area in Bhutan

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16.20 – 16.40 Community-based KAP survey on rabies among cattle Dr. Sangay Rinchen, RLDC owners in Bhutan Tsimasham 16.40 – 17.00 Panel discussion Day 3: Session 9: Disease Prevention and Control Strategies Moderator: DG / Director 9:00 - 9:20 Disease prevention and control strategy in animals Dr. Tenzin, NCAH with focus on Stepwise approach to elimination of dog-mediated rabies in human 9:20 - 9:40 Public health disease prevention and control Mr Rinzin K Jamtsho, DoPH strategy 9.40 – 10.00 Bhutan Wildlife Health Strategy : 2019 - 2028 Dr. Kinley Choden, NCD 10:00-10:20 Animal welfare with focus on dog population Dr. Karma Rinzin, DoL management in Bhutan 10:00-10.40 Panel discussion 10:40 - 11:00 Tea Break Day 3: Session 10: World Café Moderator: Dr. Pasang Tshering, OIE Consultant and One Health Core Group 11.00 – 13.00 Morning session : World Café ALL - Institutionalization of one health at every levels - Strategy for sustainable funding for one health activities - Sustainable education on one health in the institutions - Identification and prioritization of one health activities for implementation - Identification of priority one health research for implementation - Strengthening of collaboration and networking Inventory of expertise related to zoonosis/OH/Epidemiology/ lab capacity 3.00 – 14.00 Lunch Break

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Day 2: Session 7: Plenary session Moderator: One Health Core Group 14.00 – 15.30 Plenary session - World CAFÉ outcome ALL 15:30-16:00 Tea Break Day 2: Session 8: Workshop Closing Moderator: One Health Core Group 16:00-17:00 - Adoption of Workshop Resolutions - Closing remarks by MOAF - Closing remarks by MOH Rapporteurs: - Dr Sangay Rinchen, RLDC, Tsimasham - Dr Kezang Dorji, S/Jongkhar Hospital - Dr Sonam Pelden, DVH, Zhemgang - Dr Kuenzang Gyeltshen, BAFRA, Phuentsholing 14.2 Annex 2: List of participants

Dr.Tashi Samdup Director General Dr.Sithar Dorjee DoL, MoAF, Thimphu Director e-mail: [email protected] KGUMSB Thimphu Dr.Pandup Tshering e-mail: [email protected] Drector General DMS,MoH Dr.Sonam wangchuk Thimphu Chief Lab.Officer e-mail: [email protected] RCDC,MoH Serbithang Dr.Karma Lhazeen e-mail: [email protected] Director DoPH,MoH Dr.Kinley Penjor Thimphu CMO e-mail: [email protected] Dewathang Hospital

54 e-mail: [email protected] e-mail: [email protected]

Dr.Kezang Dorji Mr.Dorji Wangchuk CMO Dzongkhag Livestock Officer Samdrupjongkhar Hospital Dzongkhag Administration e-mail: [email protected] Tsirang e-mail: [email protected] Ms.Jamyang Choden Program Officer Dr.Sangay Rinchen EMSD,DMS,MoH Sr.VO Thimphu RLDC,DoL e-mail: [email protected] Tsimasham,Chhukha e-mail: [email protected] Mr.Passang Tshering Sr.Dzongkhag Health Officer Dr.R.B.Gurung Dungkhag Administration Program Director Phuentsholing,Chhukha NCAH,DoL e-mail: [email protected] Serbithang,Thimphu e-mail: [email protected] Mr.Rinzin Kinga Jamtsho Program Officer Mr.Drodhel Zangpo ZDP,DoPH,MoH Asst.Environment Officer Thimphu EACD,NEC e-mail: [email protected] Thimphu e-mail: [email protected] Ms.Sonam Choden Livestock Extension Supervisor Dr.Chendu Dorji Shershong LEC,Gelephu Sr.Veterinary Officer Sarpang Dzongkhag RLDC,DoL,MoAF e-mail: [email protected] Tsimasham,Chhukha e-mail: [email protected] Mr.Kinley Sr.Dzongkhag Health Officer Dr.Sandip Tamang Dzongkhag Administration GDMO Tsirang Chhukha BHU I

55 e-mail: [email protected] Dr.Karma Wangdi Sr.Veterinary Officer Dr.Tshering Dema LHD,DoL,MoAF GDMO Thimphu Lhamoyzingkha BHU I [email protected] e-mail: [email protected] Mr.Karchung Tshering Mr.Tshewang Norbu Sr.Laboratory Officer SPO,MoHCA MoH,Thimphu Thimphu e-mail: [email protected] e-mail: [email protected] Dr.Pema Tshewang Mr.Tshering Dorji DCVO,NAH,DoL DCLO,MoH Mothithang,Thimphu Thimphu [email protected] e-mail: [email protected] Dr.Yoriko Nishizawa Dr.Kinley Choden Neonazologist Sr.Veterinary Officer KGUMSB,THimphu Wildlife(NCD),DoFPS e-mail: [email protected] Thimphu e-mail: [email protected] Dr.Sithar Dorjee Director Dr.Heruka Mahat KGUMSB,Thimphu DCVO e-mail: [email protected] NCAH,DoL Serbithang,Thimphu Dr.Jigme Tenzin e-mail: [email protected] Dy.CFO WMD,DoFPS Dr.Yoenten Phuntshok Thimphu Sr.Veterinary Officer e-mail: [email protected] DPCU,NCAH,DoL Serbithang,Thimphu e-mail: [email protected] Mr.Rinzin Jamtsho

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CPO,MoH Sr.RQO,BAFRA Thimphu Thimphu e-mail: [email protected] e-mail: [email protected]

Ms.Yoezer Dema Mr.Kaling Dorji Sr.RQI,BAFRA Sr.RQO,BAFRA Gelephu,Sarpang Thimphu e-mail: [email protected] e-mail: [email protected]

Dr.Kuenzang Gyeltshen Mr.Naina Sing Tamang Sr.RQO,BAFRA Sr.DLO, Phentsholing,Chhukha Trashigang Dzongkhag e-mail: [email protected] [email protected]

Dr.Pema Wangchuk Mr.Purna Bdr Mahat Sr.Veterinary Officer LES,Sampheling geog Zhemgang Dzongkhag Chhhukha Dzongkhag [email protected] e-mail: [email protected]

Dr.Tenzin Wangchuk Sr.Veterinary Officer Paro Dzongkhag Ms.Sangay Zam e-mail: [email protected] Lecturer,FNPH Thimphu Dr.Sonam Pelden e-mail: [email protected] Sr.Veterinary Officer DVH,Zhemgang Dr.Narayan Pokhrel e-mail: e-mail: [email protected] Sr.Veterinary Officer Pemagyatshel Dzongkhag Dr.Karma Phuntsho e-mail: [email protected] Sr.Veterinary Officer SVL,DoL,Nganglam Dr. Karma Dorji e-mail: [email protected] GDMO,Pemagyatshel e-mail: [email protected] Dr.Kinley Penjor

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Mr.Wangchuk Dr.Sonam Wangchuk Sr.Lecturer GDMO,Yebileptsha Hospital FNPH,Thimphu [email protected] e-mail: [email protected] Mr.Sangay Tshering Mr.Lethro Tshering Lecturer Sr.Lab Officer CNR,Lobeysa NFTL,BAFRA,Yusipang [email protected] e-mail: [email protected] Mr.Jambay Dorji Sr.DLO Dr.Ngajay Jamtsho Bumthang Dzongkhag GDMO,Rangjung BHU-I e-mail: [email protected] Trashigang Dzongkhag e-mail: [email protected] Dr.Dorji Tshering Sr.Mo,Bajo Hospital Mr.Sonam Gyeltshen Wangdiphodang dzongkhag Sr.RQI,BAFRA [email protected] Samdrupjongkhar e-mail: [email protected] Dr.Chempay GDMO,MRRH Dr.Tandin Zangpo Moggar Hospital MO,Dechencholing BHU-I e-mail: [email protected] Thimphu e-mail: [email protected] Dr.Jigme Tenzin GDMO. Dr.Tenzin Lhuntse Dzongkhag PLHO, NCAH,DoL e-mail: [email protected] Serbithang,Thimphu e-mail: [email protected] Mr.DN Champagai ADLO Dr.Karma Rinzin Haa Dzongkhag CVO,DoL,MoAF e-mail: [email protected] Thimphu e-mail: [email protected] Mr.Tshewang Dakpa Accountant

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NCAH,Serbithang e-mail: [email protected] Mr.Kinzang Namgay LHS,NCAH Ms.Tshewang Dema Serbithang,Thimphu Lab.Tech e-mail: [email protected] NCAH,Serbithang

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